Saudi guidelines for the diagnosis and management of COPD

The Saudi Thoracic Society [STS] launched the Saudi Initiative for Chronic Airway Diseases [SICAD] to develop a guideline for the diagnosis and management of chronic obstructive pulmonary disease [COPD]. This guideline is primarily aimed for internists and general practitioners. Though there is scanty epidemiological data related to COPD, the SICAD panel believes that COPD prevalence is increasing in Saudi Arabia due to increasing prevalence of tobacco smoking among men and women. To overcome the issue of underutilization of spirometry for diagnosing COPD, handheld spirometry is recommended to screen individuals at risk for COPD. A unique feature about this guideline is the simplified practical approach to classify COPD into three classes based on the symptoms as per COPD Assessment Test [CAT] and the risk of exacerbations and hospitalization. Those patients with low risk of exacerbation [<2 in the past year] can be classified as either Class I when they have less symptoms [CAT < 10] or Class II when they have more symptoms [CAT >/= 10]. High-risk COPD patients, as manifested with >/= 2 exacerbation or hospitalization in the past year irrespective of the baseline symptoms, are classified as Class III. Class I and II patients require bronchodilators for symptom relief, while Class III patients are recommended to use medications that reduce the risks of exacerbations. The guideline recommends screening for co-morbidities and suggests a comprehensive management approach including pulmonary rehabilitation for those with a CAT score >/= 10. The article also discusses the diagnosis and management of acute exacerbations in COPD.

IL-4 receptor alpha single-nucleotide polymorphisms rs1805010 and rs1801275 are associated with increased risk of asthma in a Saudi Arabian population

The IL-4 receptor alpha subunit [IL-4Ralpha], when associated with the common gamma chain receptor, or the IL-13Ralpha1 subunit, transduces signals to STAT6 in response to IL-4 and IL-13 stimulations. This results in a number of cell-specific responses including Th2 differentiation, lymphocyte proliferation and IgE production. Given the prominent role of IL-4Ralpha in allergic disorders, several single-nucleotide polymorphisms [SNPs] have been found associated with asthma and other atopic disorders, including rs1805010 [I75V] and rs1801275 [Q576R] SNPs; however, lack of significant association have also been reported for some ethnic groups. The objective of this study was to determine whether IL-4Ralpha rs1805010 and rs1801275 polymorphisms are associated with asthma in patients from Saudi Arabia. One hundred and ninety severe asthmatic patients [11-70 years old] and 194 healthy subjects of equivalent age range were recruited for blood donation. DNA was purified and genotyping for rs1801275 and rs1805010 polymorphisms in the IL-4Ralpha gene was performed by PCR amplification, followed by cycle sequencing of the purified PCR fragments using BigDye chain terminator and capillary electrophoresis. Pearson's Chi-square tests showed that the minor alleles, G, for both rs1805010 and rs1801275 SNPs, were significantly more frequent in asthmatics than in the healthy group [Yates' P < 0.05]; conversely, the major alleles, A, were significantly more frequent in healthy than in asthmatics [P < 0.05]. Concerning association analysis, odds for A/G-G/G genotypes were significantly higher to be associated with asthma predisposition [rs1801275: OR = 2.12; 95% CI = 1.39-3.22; P < 0.001*; rs1805010: OR = 1.6; 95% CI = 1.01-2.53; P < 0.05*; dominant model]. Analysis of gender-genotype interactions, with genders nested within A/G-G/G, indicated higher odds for females than males of significant association with asthma [rs1801275: OR = 5.19, 95% CI = 2.09-12.94*; rs1805010: OR = 3.73, 95% CI = 2.06-6.74*]. Rs1805010 and rs1801275 were in linkage disequilibrium [D' = 0.27; P < 0.0004*], with G-G haplotype being more frequent in asthmatics than in healthy subjects [OR = 2.43, 95% CI = 1.59-3.71*].The risk alleles, G, of IL-4Ralpha rs1805010 and rs1801275 SNPs and corresponding A/G-G/G genotypes were significantly associated with asthma predisposition in asthmatics from Saudi Arabia.

Imaging lung manifestations of HIV/AIDS

Advances in our understanding of human immunodeficiency virus [HIV] infection have led to improved care and incremental increases in survival. However, the pulmonary manifestations of HIV/acquired immunodeficiency syndrome [AIDS] remain a major cause of morbidity and mortality. Respiratory complaints are not infrequent in patients who are HIV positive. The great majority of lung complications of HIV/AIDS are of infectious etiology but neoplasm, interstitial pneumonias, Kaposi sarcoma and lymphomas add significantly to patient morbidity and mortality. Imaging plays a vital role in the diagnosis and management of lung of complications associated with HIV. Accurate diagnosis is based on an understanding of the pathogenesis of the processes involved and their imaging findings. Imaging also plays an important role in selection of the most appropriate site for tissue sampling, staging of disease and follow-ups. We present images of lung manifestations of HIV/AIDS, describing the salient features and the differential diagnosis

Saudi Guidelines for testing and treatment of latent tuberculosis infection. Joint statement of the Saudi thoracic society, the Saudi society of medical microbiology and infectious diseases, the Saudi association of public health, and the society of family and community medicine

Pulmonary tuberculosis is a common disease in Saudi Arabia. As most cases of tuberculosis are due to reactivation of latent infection, identification of individuals with latent tuberculosis infection [LTBI] who are at increased risk of progression to active disease, is a key element of tuberculosis control programs. Whereas general screening of individuals for LTBI is not cost-effective, targeted testing of individuals at high risk of disease progression is the right approach. Treatment of those patients with LTBI can diminish the risk of progression to active tuberculosis disease in the majority of treated patients. This statement is the first Saudi guideline for testing and treatment of LTBI and is a result of the cooperative efforts of four local Saudi scientific societies. This Guideline is intended to provide physicians and allied health workers in Saudi Arabia with the standard of care for testing and treatment of LTBI

calcified lung nodule: what does it mean?

The aim of this review is to present a pictorial essay emphasizing the various patterns of calcification in pulmonary nodules [PN] to aid diagnosis and the pathogenesis where it is known. The imaging evaluation of PN is based on clinical history, size, distribution and the gross appearance of the nodule as well as feasibility of obtaining a tissue diagnosis. Imaging is instrumental in the management of PN and one should strive not only to identify small malignant tumors with high survival rates but to spare patients with benign PN from undergoing unnecessary surgery. The review emphasizes how to achieve these goals. One of the most reliable imaging features of a benign lesion is a benign pattern of calcification and periodic follow-up with computed tomography showing no growth for 2 years. Calcification in PN is generally considered as a pointer toward a possible benign disease. However, as we show here, calcification in PN as a criterion to determine benign nature is fallacious and can be misleading. The differential considerations of a calcified lesion include calcified granuloma, harmartome, carcinoid, osteosarcoma, chondrosarcoma and lung metastases or a primary bronchogenic carcinoma among others. We describe and illustrate different patterns of calcification as seen in PN on imaging

Levels of acceptance of asthma control test questionnaire among Saudi patients attending 5 tertiary care hospitals in Saudi Arabia

To explore the levels of acceptance of asthma control test [ACT] among Saudi patients. A cross-sectional survey was carried out in 5 hospitals in Riyadh, Kingdom of Saudi Arabia, namely; Security Forces Hospital, King Abdul-Aziz Medical City, King Khalid University Hospital, King Faisal Specialist Hospital, and Riyadh Armed Forces Hospital, from the first of September to the 30th of November 2006. Patients attending the pulmonary clinic were asked to answer the ACT. This was followed by an interview to assess their view on the questions and their level of difficulty. The total number of patients was 1060. Males constituted 41%. A third of the patients were uneducated. The majority of patients [94%] found the ACT questions easy. The younger patients found the ACT questions easier to answer than the older patients. Ninety-five percent of males found the ACT easy, while only 92% of females found the ACT easy. Educated patients found the ACT questions easy to perform more often than uneducated patients. There are no significant differences for age and gender, and for the question on whether the test helped to understand the patient's condition. There are no significant differences for age and education, and for the question on whether the patient is willing to perform the test in each clinic visit. The majority of Saudi patients found the ACT easy, and they are willing to repeat the test every clinic visit

Saudi initiative for asthma

The Saudi Initiative for Asthma [SINA] provides up-to-date guidelines for healthcare workers managing patients with asthma. SINA was developed by a panel of Saudi experts with respectable academic backgrounds and longstanding experience in the field. SINA is founded on the latest available evidence, local literature, and knowledge of the current setting in Saudi Arabia. Emphasis is placed on understanding the epidemiology, pathophysiology, medications, and clinical presentation. SINA elaborates on the development of patient-doctor partnership, self-management, and control of precipitating factors. Approaches to asthma treatment in SINA are based on disease control by the utilization of Asthma Control Test for the initiation and adjustment of asthma treatment. This guideline is established for the treatment of asthma in both children and adults, with special attention to children 5 years and younger. It is expected that the implementation of these guidelines for treating asthma will lead to better asthma control and decrease patient utilization of the health care system

Prevalence of symptoms and risk of sleep apnea in middle-aged Saudi males in primary care

The prevalence of obstructive sleep apnea OSA has not been assessed in Saudi Arabia. We aimed to assess the prevalence of individuals who were at risk of OSA in a sample of middle-aged Saudi males, using the Berlin questionnaire at primary care settings. The study was conducted at King Khalid University and King Fahd National Guard primary health care clinics in Riyadh, Kingdom of Saudi Arabia between December 2005 and March 2006. Berlin Questionnaire was administered by trained medical students to consecutive Saudi male patients in the age group 30-65 years attending the primary health care clinics, after explaining the procedure of the study. Based on the data collected and defined criteria, patients were stratified into high risk and low risk according to responses. Five hundred and seventy-eight middle-aged Saudi males with a mean age of 45.02 +/- 9.3 year were surveyed in this study. Snoring was present in 52.3%, and breathing pauses more than once per week was noticed in 11.3%. Based on the Berlin questionnaire stratification for risk of OSA, 33.3% were considered as high risk patients for OSA. The occurrence of daytime tiredness >once/week was reported by 35.5%. The prevalence of snoring and risk for OSA is similar to that reported in the US. In primary care setting, one in 3 middle-aged Saudi males is at risk for OSA

Asthma control assessment using asthma control test among patients attending 5 tertiary care hospitals in Saudi Arabia

Evaluation of asthma control using the Asthma Control Test ACT. The ACT was used to assess asthma control among patients with bronchial asthma visiting pulmonary clinics in 5 major tertiary care hospitals in Riyadh, Kingdom of Saudi Arabia. Each hospital had a target of 300 patients to recruit over the period of the study from the 1st September to 30th November 2006. The total number of patients studied was 1,060 patients. Males constituted 442 42% and females constituted 618 58%, the median age was 38.56 years range 15-75. One third of patients had no formal education. The ACT score revealed uncontrolled asthma in 677 64%, well-controlled asthma in 328 31%, and complete controlled in 55 5%. There are no significant correlations between the age below 40 and above 40 years and level of asthma control p=0.12. However, the younger age group less than 20 had better control of asthma in comparison with older patients p=0.0001. There was a significant correlation between level of asthma control and gender, males 44% had better asthma control than females 30% p=0.0001. Control of bronchial asthma is still a major concern in our population. Further studies are needed to explore the factors leading to poor asthma control

Sinus histiocytosis with massive lymphadenopathy [Rosai-Dorfmans Disease] as cause of isolated hilar lymphadenopathy and complete remission after high dose steroid

Rosai-Dorfman's Disease, also known as sinus histiocytosis with massive lymphadenopathy SHML, is a rare histiocytic proliferative disorder and a distinct clinico-pathological feature of unknown origin. Painless cervical lymphadenopathy is the most common clinical presentation. Different treatment modalities have been tried with variable responses, however, there is no consensus on the best modality of treatment. Here, we present a case report of SHML causing isolated hilar lymphadenopathy with complete remission for more than 6 years, after a short course of high dose steroid dexamethasone 20 mg daily for 3 days

fatal complication of bronchiectasis. brain abscess with intraventricular rupture

The classic clinical manifestations of bronchiectasis are cough and daily production of purulent sputum for months to years. The most common complications are hemoptysis and respiratory failure. Brain abscess has become rare in the recent antibiotic era. In this report, we present a case of bronchiectasis complicated by brain abscesses. Despite the early diagnosis and appropriate management, and while the condition of the patient was improving, an intraventricular abscess rupture led to rapid coma then death. Presentation and management of this potentially fatal complication of bronchiectasis are discussed

Implementation of the national asthma management guidelines in the emergency department

The national protocol for asthma management was released in 1995. There has been no national investigation to compare the actual care delivered at the Emergency Department to those recommended by these guidelines: To compare the documented management of acute bronchial asthma at the Emergency Room [ER] with the Saudi National Guidelines Retrospective analyses of a total of 150 ER records, of patients with a diagnosis of asthma over a one year period [January through to December 2000], at King Abdul-Aziz Medical City, King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia. Documentation of the history, indices of severity, treatment given, pre-discharge assessment and prescriptions were compared to the nationally recommended management. History of the present attack, its duration, frequency of b-agonist use and nocturnal symptoms were documented in less than 50% of patients. Previous ER visits and hospitalization, peak flow rate and accessory muscle use were similarly recorded in less than 50% of patients whereas intensive care unit admission and intubation were documented in less than 15% of asthmatics. Steroids were given to only 46% of patients with acute asthma who visited the Emergency Department. Pre-discharge clinical assessment and peak flow readings were documented in 48% and 29%. Only 64% of patients were given a follow up appointment. The documented treatment of patients with an acute asthmatic episode at the ER varies significantly from what is recommended by the National and International Asthma Management Guidelines. Failure to implement Asthma Guidelines probably results in an inadequate care of asthmatic patients and raises the urgent need for a National Physician Asthma Education Program