Saudi clinical practice guideline for the diagnosis of the first deep venous thrombosis of the lower extremity

The diagnosis of deep venous thrombosis [DVT] may be challenging due to the inaccuracy of clinical assessment and diversity of diagnostic tests. On one hand, missed diagnosis may result in life-threatening conditions. On the other hand, unnecessary treatment may lead to serious complications. As a result of an initiative of the Ministry of Health of the Kingdom of Saudi Arabia [KSA], an expert panel led by the Saudi Association for Venous Thrombo-Embolism [SAVTE; a subsidiary of the Saudi Thoracic Society] with the methodological support of the McMaster University Working Group, produced this clinical practice guideline to assist healthcare providers in evidence-based clinical decision-making for the diagnosis of a suspected first DVT of the lower extremity. Twenty-four questions were identified and corresponding recommendations were made following the Grading of Recommendations, Assessment, Development and Evaluation [GRADE] approach. These recommendations included assessing the clinical probability of DVT using Wells criteria before requesting any test and undergoing a sequential diagnostic evaluation, mainly using highly sensitive D-dimer by enzyme-linked immunosorbent assay [ELISA] and compression ultrasound. Although venography is the reference standard test for the diagnosis of DVT, its use was not recommended

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.

Pulmonary rehabilitation: a regional perspective evidenced-based review

Pulmonary rehabilitation [PR] is an integral component of the comprehensive management plan of patients with chronic lung diseases by addressing their functional and psychological deficits. PR is generally recommended to symptomatic patients with chronic lung diseases who develop shortness of breath on their own pace at level ground while receiving optimum therapy. From a regional perspective, this review covers the description of a PR program, its establishment and outcome assessment

prevalence and characteristics of water-pipe smoking among high school students in Saudi Arabia

To identify the prevalence and predictors of the water-pipe [WP] smoking epidemic in the Kingdom of Saudi Arabia [KSA]. A cross-sectional study conducted with 16-18 year-old high school students in Riyadh, Saudi Arabia. Of the 1272 participants, 414 [33.0%] reported having tried WP smoking. Of this group, 141 [34.1%] were female and 273 [65.9%] were male. Further, 129 [10.2%] students were current WP smokers who had used at least one rock in the past month; 20 were female [1.6%] and 120 were male [8.6%]. Regarding age, 276 [68.1%] students who tried WP smoking at least once began when they were over 11 years of age, whereas 129 [31.9%] began WP smoking at or before 11 years of age. Adjusted odds ratios showed that trying WP smoking at least once was associated with smoking after the age of 11 [p = 0.021, OR 7.7; CI: 1.4-43.6] and accepting water-pipes from a friend [p = 0.024, OR 10.6; CI: 1.4-83.4]. A high prevalence of WP smoking exists among male and female high schools students in Riyadh, KSA. WP smoking was reported to begin in early adulthood. WP smoking [water-pipe smoking], KSA [Kingdom of Saudi Arabia], STS [Saudi Thoracic Society], GYTS [Global Youth Tobacco Survey], CI [confidence interval]

Saudi initiative for asthma - 2012 update: guidelines for the diagnosis and management of asthma in adults and children

This an 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 SINA is to have updated guidelines, which are simple to understand and easy to use by non-asthma specialists, including primary care and general practice physicians. This new version includes updates of acute and chronic asthma management, with more emphasis on the use of Asthma Control Test in the management of asthma, and a new section on "difficult-to-treat asthma." Further, the section on asthma in children was re-written to cover different aspects in this age group. The SINA panel is a group of Saudi experts with well-respected academic backgrounds and experience in the field of asthma. The guidelines are formatted based on the available evidence, local literature, and the current situation in Saudi Arabia. There was an emphasis on patient-doctor partnership in the management that also includes a self-management plan. The approach adopted by the SINA group is mainly based on disease control as it is the ultimate goal of treatment

Predicting tobacco use among high school students by using the global youth tobacco survey in Riyadh, Saudi Arabia

To identify the predictors that lead to cigarette smoking among high school students by utilizing the global youth tobacco survey in Riyadh, Kingdom of Saudi Arabia [KSA]. A cross-sectional study was conducted among high school students [grades 10-12] in Riyadh, KSA, between April 24, 2010, and June 16, 2010. The response rate of the students was 92.17%. The percentage of high school students who had previously smoked cigarettes, even just 1-2 puffs, was 43.3% overall. This behavior was more common among male students [56.4%] than females [31.3%]. The prevalence of students who reported that they are currently smoking at least one cigarette in the past 30 days was 19.5% [31.3% and 8.9% for males and females, respectively]. "Ever smoked" status was associated with male gender [OR = 2.88, confidence interval [CI]: 2.28-3.63], parent smoking [OR = 1.70, CI: 1.25-2.30] or other member of the household smoking [OR = 2.11, CI: 1.59-2.81] who smoked, closest friends who smoked [OR = 8.17, CI: 5.56-12.00], and lack of refusal to sell cigarettes [OR = 5.68, CI: 2.09-15.48]. Several predictors of cigarette smoking among high school students were identified

Prevalence of chronic obstructive pulmonary disease among smokers attending primary healthcare clinics in Saudi Arabia

The prevalence of chronic obstructive pulmonary disease [COPD] in Saudi Arabia is unknown. The aim of this study was to estimate the prevalence of COPD among smokers more than 40 years of age attending primary healthcare clinics in Saudi Arabia. A questionnaire was used in a cross-sectional collection of demographic data and other items related to diagnosis of COPD in patients visiting primary healthcare clinics. Eligible subjects were current or ex-smokers and aged 40 years or above. Spirometry was performed according to American Thoracic Society criteria. Airflow obstruction was classified according to the 2003 update of the World Health Organization and Global Initiative for Chronic Obstructive Lung Disease criteria. COPD was defined as a ratio less than 0.70 of post-bronchodilator-predicted forced expiratory volume in the first second to forced vital capacity [FEV1/FVC <0.70]. Because of incomplete data or poor performance on spirometry, of 1380 subjects eligible for the study, only 501 subjects were eligible for data analysis. Seventy-one patients had an FEV1/FVC ratio <0.70, comprising 14.2% of the study population, of which 95.8% were males. Current smokers comprised 57 [80.3%] subjects. Of the 71 subjects who fulfilled the criteria for COPD diagnosis, none were found to be in COPD stage I; 40 [56.3%] were in stage II and 31 [43.6%] were in stage III of the disease. Underdiagnosis of COPD in primary healthcare clinics in Saudi Arabia is common, but its extent is not different from the corresponding data available in the literature for other countries. Use of spirometry as a routine test for all patients older than 40 years of age and with a smoking history can help in early detection and proper diagnosis of COPD, which subsequently will help in implementation of preventive measures

Prevalence and characteristics of cigarette smoking among 16 to 18 years old boys and girls in Saudi Arabia

To study the prevalence and characteristics of cigarette smoking among secondary school students [16- to 18-year-old boys and girls] in Riyadh city, Saudi Arabia. We applied a standard two-stage, cross-sectional study design. Secondary schools for both boys and girls in Riyadh city were randomly selected using a cluster sampling method. We used the global youth tobacco survey [GYTS] tool to achieve our objectives. Among 1272 students [606 boys and 666 girls], the prevalence of those ever smoked cigarettes was 42.8% [55.6% of boys and 31.4% of girls]. The prevalence of current smoking was 19.5% [31.2% of boys and 8.9% of girls]. Despite the fact that the majority of students think smoking is harmful, most do not wish to stop smoking, and they had not tried to stop in the past year. Cigarette smoking is significantly associated with the male gender, having friends who smoke, and having parents who smoke, but is not significantly associated with the type of school attended. Smoking prevalence among secondary schools students in Saudi Arabia is high and alarming. There is a need to implement an education program about the risks of smoking and to include parents and friends as healthy models to prevent students from beginning to smoke

reliability of an Arabic translation of the chronic obstructive pulmonary disease assessment test

To produce a conceptually equivalent Arabic version of the Chronic Obstructive Pulmonary Disease [COPD] Assessment Test [CAT], and to assess its reliability. A prospective observational study was carried out from June 2010 to September 2010 at King Abdulaziz Medical City and King Khalid University Hospital, Riyadh, Saudi Arabia. We conducted this study in 2 phases. Phase 1: the translation of the CAT from English to Arabic, through forward and backward translation, as well as pilot testing. Phase 2: assessment of the test-retest reliability of the CAT for 45 patients with COPD who received optimal care by their pulmonologist. This study was conducted on 45 participants. The CAT mean total [ +/- SD] score at the test session was 10.7 +/- 5.8, and 9.2 +/- 4.5 at the re-test session. The interclass correlation of the total score was 0.9 [p=0.000076]. The strongest correlation was for the item of confidence in leaving home with a value of 0.92 [p=0.000082], whereas the weakest was for the item related to sleep with a value of 0.53 [p=0.007]. The Arabic version of the CAT was found to be easy to administer, reliable, and had a strong interclass correlation reflecting stability over time and across the items

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

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

Effect of moderately high altitude on the pattern of lung disease

In high altitude areas, inspired atmospheric oxygen decreases proportionally to the vertical distance from sea level. Population in these areas acquire some adaptive mechanisms to cope with the relatively hypoxic environment. This study compares populations who live in highland areas [2500 meters above sea level] with those in lowland areas [close to sea level]. No differences were observed in the prevalence or mortality rate of respiratory diseases between these two groups. It is concluded that even if adaptive mechanisms can be observed in dwellers of moderately high altitude [<3000 m above sea level], such altitude does not adversely affect the pattern of respiratory disease in these populations. However, partial pressure of oxygen [PaO[2]] tends to be lower in individuals of high altitude areas, leading to marked oxygen desaturation when such individuals encounter a significant respiratory illness. Physicians are advised to introduce early and effective therapeutic measures before such deterioration occurs

Prevalence of tuberculosis in the western region of Saudi Arabia

A sample survey in the Western region of Saudi Arabia was conducted to determine the prevalence of tuberculosis infection by Mantoux testing. A total of 1824 subjects were studied. The prevalence of tuberculin positivity [>/= 10 mm] among subjects with no previous BCG vaccination was found to be 9% in age group 5-14 years. putting this region midway between low [2%] and middle [14%] prevalence countries of the world. This prevalence increased progressively with age to 51% in age group 45-64 years, showing that a substantial pool of infected people exists who can break down into active disease and spread infection in the community. It was higher among males than females, among urbans than rurals, and among non-Saudi than Saudi population. BCG-induced tuberculin positivity was found to wane in most cases; only 12% were Mantoux positive among BCG vaccinated subjects aged 5-14 years, therefore, a positive Manoux test in them can be taken as an indicator of infection by tubercle bacilli rather than due to BCG vaccination. Marked increase in Mantoux positivity in age group 15-24 years [19% in BCG negative. 30% in BCG positive subjects] suggests that revaccination with BCG at school leaving age may be useful in this population