Middle East respiratory syndrome coronavirus in Al-Madinah City, Saudi Arabia: Demographic, clinical and survival data

Background: Middle East respiratory syndrome coronavirus [MERS-CoV], is an emerging virus respiratory infection. It has a high mortality rate and a wide spectrum of clinical features. This study describes the clinical characteristics and outcome of MERS infected patients

Methods: A retrospective study was conducted of all confirmed MERS-CoV infections from March 2014 to May 2014 at two tertiary care hospitals in Al-Madinah region [Saudi Arabia]. We gathered data about demographic, clinical presentation, and factors associated with severity and mortality

Results: A total of 29 cases were identified; 20 males [69%] and nine females [31%], age 45 +/- 12 years. The death rate was higher for men [52%] than for women [23%]. Initial presentation was fever in 22 [75%] cases, cough in 20 [69%] cases, and shortness of breath in 20 [69%] cases. Associated comorbidities were diabetes mellitus in nine [31%] patients and chronic kidney disease [CKD] in eight [27%] patients. Duration of symptoms before hospitalization ranged from 2.9 days to 5 days. Elevated liver enzymes were present in 14 [50%] patients and impaired renal profile present in eight [27%] patients. We also describe in this study radiological patterns and factors associated with mortality

Conclusion: MERS-CoV infection transmission continues to occur as clusters in healthcare facilities. The frequency of cases and deaths is higher among men than women and among patients with comorbidities

Factors associated with poor asthma control in the outpatient clinic setting

The goal of the study was to assess asthma control using asthma control test [ACT] and to explore the factors that effects asthma control among participants with bronchial asthma in the outpatient clinic setting. This cross-sectional descriptive study was conducted in the outpatient primary care clinic at King Abdulaziz Medical City in Riyadh. Adult patients who were diagnosed with bronchial asthma by their primary treating physician were recruited over a 6-month period. Patients completed the ACT and questionnaires, which identified factors that affect asthma control. Four hundred asthmatic patients [n = 400] were enrolled, and 70% of these patients were women. Fifty-four percent of patients inappropriately used the inhaler device. The estimated prevalence of uncontrolled asthma at the time of the study was 39.8%. Inappropriate device use by the patient was more frequently associated with uncontrolled asthma [P - value = 0.001]. Active smoking [P - value = 0.007], passive smoking [P - value = 0.019], unsealed mattress [P - value = 0.030], and workplace triggers [P - value = 0.036] were also associated with uncontrolled asthma. However, the extent of asthma control did not appear to be related to the existence of regular follow-ups, bedroom carpets, outpatient clinic visits, age, body mass index [BMI], or duration of asthma. The present study identified a high prevalence of uncontrolled asthma in the primary outpatient clinic setting and common risk factors that may contribute to poor asthma control

Poor asthma education and medication compliance are associated with increased emergency department visits by asthmatic children

Acute exacerbations of bronchial asthma remain a major cause of frequent Emergency Department [ED] visits by pediatric patients. However, other factors including psychosocial, behavioural and educational, are also reportedly associated with repetitive ED visits. Therefore, it is necessary to determine whether such visits are justifiable. The objective of this cross-sectional study was to identify risk factors associated with visits to ED by asthmatic children. Asthmatic children [n= 297] between 1-17 years old were recruited and information collected at the time of visiting an ED facility at two major hospitals. Asthmatic patients visited the ED 3.9 3.2 times-per-year, on average. Inadequately controlled asthma was perceived in 60.3% of patients. The majority of patients [56.4%] reported not receiving education about asthma. Patients reflected misconceptions about the ED department, including the belief that more effective treatments are available [40.9%], or that the ED staff is better qualified [27.8%]. About half of patients [48.2%] visited the ED because of the convenience of being open 24 hours, or because they are received immediately [38.4%]. Uncontrolled asthma was associated with poor education about asthma and/or medication use. Patients educated about asthma, were less likely to stop corticosteroid therapy when their symptoms get better [OR:0.55; 95% CI:0.3-0.9;P= 0.04]. This study reports that most patients had poor knowledge about asthma and were using medications improperly, thus suggesting inefficient application of management action plan. Unnecessary and frequent visits to the ED for asthma care was associated with poor education about asthma and medication use. Potential deficiencies of the health system at directing patients to the proper medical facility were uncovered and underline the necessity to improve education about the disease and medication compliance of patients and their parents/guardians

Community- versus nosocomial-acquired severe sepsis and septic shock in patients admitted to a tertiary intensive care in Saudi Arabia, etiology and outcome

Sepsis syndrome is a major worldwide cause of morbidity and mortality. While community-acquired severe sepsis and septic shock constitutes a major cause of admission to the intensive care unit, hospital-acquired severe sepsis and septic shock remain major preventable causes of ICU admission. This study evaluates the rate, etiology, complication and outcome of community- and hospital-acquired sepsis in a tertiary care hospital in Saudi Arabia. This is a retrospective evaluation of all admissions with severe sepsis and septic shock to a general intensive care unit over a period of six months. A total number of 96 patients were included, which represented 15% of the total number of admissions during the study period. The mean age was 57.4 [SD 21]. Sixty percent of cases were due to hospital-acquired infections, and 40% were community-acquired. The majority of the infections acquired in the hospital occurred in medical wards and intensive care units [27% and 21%, respectively]. At least one co-morbid condition was present in 94% of the sample patients, with cardiovascular disease and diabetes being the most frequently encountered disorders [58%]. Both community and hospital-acquired severe sepsis and septic shock carry very high mortality [58%]. The ICU length of stay was significantly longer for hospital and ICU acquired infections. Both community and hospital-acquired infections carry high mortality. Hospital-acquired severe sepsis is frequent in medical wards and ICUs, and measures to further evaluate risk factors are prudent

Validation of the arabic version of the epworth sleepiness scale

The Epworth Sleepiness Scale [ESS] is a questionnaire widely used in developed countries to measure daytime sleepiness and diagnose sleep disorders. This study aimed to develop an ESS questionnaire for the Arabic population [ArESS], to determine ArESS internal consistency, and to measure ArESS test-retest reproducibility. It also investigated whether the normal range of ESS scores of healthy people in different cultures are similar. The original ESS questionnaire was translated from English to Arabic and back-translated to English. In both the English and Arabic translations of the survey, ESS consists of eight different situations. The subject was asked to rate the chance of dozing in each situation on a scale of 0-3 with total scores ranging between 0 [normal sleep] and 24 [very sleepy]. An Arabic translation of the ESS questionnaire was administered to 90 healthy subjects. Item analysis revealed high internal consistency within ArESS questionnaire [Cronbach's alpha = 0.86 in the initial test, and 0.89 in the retest]. The test-retest intra-class correlation coefficient [ICC] shows that the test-retest reliability was substantially high: ICC = 0.86 [95% confidence interval: 0.789-0.909, p-value < 0.001]. The difference in ArESS scores between the initial test and retest was not significantly different from zero [average difference = -0.19, t = -0.51, df = 89, p-value = 0.611]. In this study, the averages of the ESS scores [6.3 +/- 4.7, range 0-20 in the initial test and 6.5 +/- 5.3, range 0-20 in the retest] are considered high in Western cultures. The study shows that the ArESS is a valid and reliable tool that can be used in Arabic-speaking populations to measure daytime sleepiness. The current study has shown that the average ESS score of healthy Arabian subjects is significantly higher than in Western cultures

Pictorial review of intrathoracic manifestations of progressive systemic sclerosis

Intra-thoracic manifestations of progressive systemic sclerosis [PSS] are not well known particularly the imaging features, which forms the basis of accurate and timely diagnosis. The aim of this study is to familiarize the physicians and radiologists with these features. The diagnosis can remain elusive because of the non-specific nature of symptoms which mimic many common conditions. Thus, the diagnosis of PSS can be missed leading to continuous morbidity if the correct imaging is not pursued. The authors examined the records of rheumatology patient referrals of over a 5 year period. A hundred and seventy patients with systemic sclerosis and mixed connective tissue disorders were chosen for detailed study of the imaging available, which form the basis of this review. The images included conventional chest radiographs, digital radiographs computed radiography [CT] and high resolution computed tomography [HRCT]. Where applicable computed pulmonary angiography [CTPA] and radionuclide scans were also interrogated

Atypical radiological manifestations of thoracic sarcoidosis: a review and pictorial essay

Thoracic sarcoidosis is a common disease, with well-described and recognizable radiographic features. Nevertheless, most physicians are not familiar with the rare atypical often-confusing manifestations of thoracic sarcoid. Although these findings have been previously reviewed, but more recent advances in imaging and laboratory science, need to be incorporated. We present a review of literature and illustrate the review with unpublished data, intended to provide a more recent single comprehensive reference to assist with the diagnosis when atypical radiographic findings of thoracic sarcoidosis are encountered. Thoracic involvement accounts for most of morbidity and mortality associated with sarcoidosis. An accurate timely identification is required to minimize morbidity and mortality. It is essential to recognize atypical imaging findings and relate these to clinical manifestations and histology

Comparison of the tuberculin skin test and Quanti-FERON-TB Gold In-Tube [QFT-G] test for the diagnosis of latent tuberculosis infection in dialysis patients

Dialysis patients are more likely than the general population to develop active tuberculosis [TB]. In these patients, the availability of a highly sensitive and specific test to diagnose latent TB will ensure earlier treatment and decreased progression to active disease. In the current study, the Quanti-FERON-TB Gold In-Tube [QFT-G] test was compared with the tuberculin skin test [TST] for the diagnosis of latent tuberculosis infection [LTBI] among 200 hemodialysis patients and 15 confirmed TB disease cases in a tertiary care center in Saudi Arabia. Among the LTBI cases, 26 [13%] were TST positive, and 65 [32.5%] were positive by the QTF-G test, with an overall agreement between the 2 tests of 75.5% [k = 0.34] being observed. Among the confirmed tuberculosis disease cases, none were positive by TST, and 10 [66.7%] were positive by the QTF-G test, resulting in an overall agreement of 33.3% [k = 0]. A comparison between the TST and the QTF-G test was performed based on the sensitivity, specificity, and area under the curve [AUC] obtained for the tests. The QTF-G test was more sensitive and less specific than the TST in predicting the confirmed TB disease cases. When we tested the correspondence of the AUC values between the 2 diagnostic modalities, the obtained p-value was 0.0003. In conclusion, the AUCs of the examined diagnostic modalities are significantly different in predicting LTBI and tuberculosis

Saudi regulations for the accreditation of sleep medicine physicians and technologists

The professional content of sleep medicine has grown significantly over the past few decades, warranting the recognition of sleep medicine as an independent specialty. Because the practice of sleep medicine has expanded in Saudi Arabia over the past few years, a national regulation system to license and ascertain the competence of sleep medicine physicians and technologists has become essential. Recently, the Saudi Commission for Health Specialties formed the National Committee for the Accreditation of Sleep Medicine Practice and developed national accreditation criteria. This paper presents the newly approved Saudi accreditation criteria for sleep medicine physicians and technologists

Guidelines for the role of FDG-PET/CT in lung cancer management

Fluoro-2-deoxy-D-glucose [FDG]-positron emission tomography [PET] and PET/computed tomography [FDG-PET/CT] is regarded as a standard of care in the management of non-small-cell lung carcinoma [NSCLC] and is a useful adjunct in the characterization of indeterminate solitary lung nodules [SLN], and pre-treatment staging of NSCLC, notably mediastinal nodal staging and detection of remote metastases. FDG-PET/CT has the ability to assess locoregional lymph node spread more precisely than CT, to detect metastatic lesions that would have been missed on conventional imaging or are located in difficult areas, and to help in the differentiation of lesions that are equivocal after conventional imaging. Increasingly FDG-PET/CT is employed in radiotherapy planning, prediction of prognosis in terms of tumor response to neo-adjuvant, radiation and chemotherapy treatment. Evidence is accumulating of usefulness of PET/CT in small cell lung cancer.

Eosinophilic pneumonia: experience at two tertiary care referral hospitals in Saudi Arabia

Eosinophilic lung diseases are a diverse group of disorders characterized by pulmonary opacities associated with tissue or peripheral eosinophilia. A retrospective study conducted at two tertiary care hospitals from January 1999 to December 2009. All cases with the diagnosis of pulmonary eosinophilia were reviewed over a period of 10 years. Data on demographic, clinical, and radiologic characteristics were collected. Thirty-five patients with a mean age of 33.9 [16.2] years, of which 20 [57.1%] were male and meeting the criteria of eosinophilic lung disease were identified. Cough and dyspnea were the most frequent symptoms at presentation in 29 [82.9%] and 27 [77.1%] patients, respectively. Reticulonodular and airspace patterns were the most common radiographic findings in 17 [48.6%] and 15 [42.9%] patients, respectively. Peripheral eosinophilia was present in 33 [94.3%] patients. Twenty-four patients [68.6%] were labeled as having idiopathic pulmonary infiltrate with eosinophilia. Complete remission was achieved in 13 [54.2%] of 24 patients, while 10 [41.7%] patients relapsed within a few months of discontinuation of therapy. Specific therapy for a specific disease was administered in 8 patients: 2 patients for pulmonary tuberculosis, 2 for Churg-Strauss syndrome, 1 for lymphoma, 1 for schistosomiasis, 1 for acute eosinophilic pneumonia, and 1 for Wegener granuloma; 3 patients were treated as allergic bronchopulmonary aspergillosis. Pulmonary eosinophilia remains rare but challenging, and it can have the same diverse clinical and radiographic presentations seen with other common pulmonary conditions. Clinicians should be alert to these syndromes and must think of them in any lung disease differential diagnoses

Pulmonary vascular complications of chronic liver disease: pathophysiology, imaging, and treatment

To review the pathogenesis of pulmonary vascular complications of liver disease, we discuss their clinical implications, and therapeutic considerations, with emphasis on potential reversibility of the hepatopulmonary syndrome after liver transplantation. In this review, we also discuss the role of imaging in pulmonary vascular complications associated with liver disease

Home intravenous antibiotics in a tertiary care hospital in Saudi Arabia

Home intravenous [IV] antibiotic programs are becoming increasingly popular worldwide because of their efficacy and safety. However, in Saudi Arabia these programs have not yet become an integrated part of the health care system. We present our experience with a home IV antibiotic program, as one of the major health care providers in Saudi Arabia. Retrospective chart review of patients enrolled in the King Abdulaziz Medical City Home Health Care IV Antibiotic Program from 1 May 2005 [the start of the program] until 30 December 2007. In addition to demographic characteristics, we collected data on the site of infection, the clinical diagnosis, the isolated microorganisms, and the type of antibiotics given. Outcome measures evaluated included the relapse rate, failure rate, the safety of the program, and readmission rates. Of the 1 55 patients enrolled, 1 52 patients completed the program. Those who completed the program had a mean [SD] age of 52.8 [23.9] years. The mean [SD] duration of the IV antibiotic treatment was 20.6 [17] days. Three patients refused to complete the intended duration of therapy. Peripherally inserted central catheter [PICC] lines were utilized in 130 patients [86%]. One-hundred and thirty-one patients completed the intended duration of therapy, although the therapy was changed from the initial plan for 21 [13.8%] patients. Readmission to the hospital during therapy was required for 13 patients [8.5%]. Osteomyelitis was the most frequently encountered diagnosis [65 patients, 42.8%], followed by urinary tract infection [36 patients, 23.7%]. The home health care-based IV antibiotic program was an effective and safe alternative for in-patient management of patients with non-life-threatening infections, and was associated with a very low complication rate. Home IV antibiotic programs should be used more frequently as part of the health care system in Saudi Arabia

Reading chest radiographs in the critically ill [Part II]: Radiography of lung pathologies common in the ICU patient

This is part II of two series review of reading chest radiographs in the critically ill. Conventional chest radiography remains the cornerstone of day to day management of the critically ill occasionally supplemented by computed tomography or ultrasound for specific indications. In this second review we discuss radiographic findings of cardiopulmonary disorders common in the intensive care patient and suggest guidelines for interpretation based not only on imaging but also on the pathophysiology and clinical grounds

Bronchiolitis obliterans organizing pneumonia: experience at three hospitals in Riyadh

Because reports of bronchiolitis obliterans organizing pneumonia [BOOP] are lacking from the Middle East, we conducted a retrospective review of all histopathologically proven cases of BOOP over a 10-year period at three tertiary care hospitals in Riyadh and describe the clinical features and outcome. Charts at the three hospitals were searched using a specific code for BOOP or cryptogenic organizing pneumonia [COP]. Lung specimens had to show histological proof of BOOP with a compatible clinical picture. Chest radiographs and high-resolution CT scans were reviewed. Twenty cases of biopsy-proven BOOP had well-documented clinical and radiographic data. There were 11 males and 9 females [mean age, 58 years; range, 42-78]. The clinical presentation of BOOP was acute or subacute pneumonia-like illness with cough [85%], fever [70%] dyspnea, [85%] and crackles [80%]. The most frequent radiological pattern was a bilateral alveolar infiltrate. The most common abnormality on pulmonary function testing [n=14] was a restrictive pattern [11 patients]. Most patients [70%] had no underlying cause [idiopathic BOOP]. Other associations included thyroid cancer, rheumatoid arthritis, syphilis and Wegner's granulomatosis. Ten patients [50%] had a complete response to steroids, 6 [30%] had a partial response and 3 [15.8%] with secondary BOOP had rapid progressive respiratory failure and died. The clinical presentation of BOOP in our patients is similar to other reported series. A favorable outcome occurs in the majority of cases. However, BOOP may occasionally be associated with a poor prognosis, particularly when associated with an underlying disease