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
April-June 2022
Volume 17 | Issue 2
Page Nos. 71-135

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REVIEW ARTICLE  

Challenges and recommendations for the management of asthma in the Middle East and Africa Highly accessed article p. 71
Mohamed Omar Zeitouni, Mohamed Saad Al-Moamary, Marie Louise Coussa, Moussa Riachy, Bassam Mahboub, Fatma AlHuraish, Mohamed Helmy Zidan, Mohamed Mostafa Metwally, Kurtuluş Aksu, Erdinç Yavuz, Ismail Sikander Kalla, Jeremiah Chakaya, Snouber Abdelmadjid, Habib Ghedira
DOI:10.4103/atm.atm_469_21  
Clinical presentation of asthma is variable, and its diagnosis can be a major challenge in routine health-care practice, especially in low-and-middle-income countries. The aim of asthma management is to achieve optimal asthma control and to reduce the risk of asthma exacerbations and mortality. In the Middle East and in Africa (MEA), several patient- and physician-related factors lead to misdiagnosis and suboptimal management of asthma. A panel of experts comprising of specialists as well as general health-care professionals met to identify challenges and provide recommendations for the management of asthma in MEA. The major challenges identified for diagnosis of asthma were lack of adequate knowledge about the disease, lack of specialized diagnostic facilities, limited access to spirometry, and social stigma associated with asthma. The prime challenges for management of asthma in MEA were identified as overreliance on short-acting β-agonists (SABAs), underprescription of inhaled corticosteroids (ICS), nonadherence to prescribed medications, and inadequate insurance coverage for its treatment. The experts endorsed adapting the Global Initiative for Asthma guidelines at country and regional levels for effective management of asthma and to alleviate the overuse of SABAs as reliever medications. Stringent control over SABA use, discouraging over-the-counter availability of SABA, and using as-needed low-dose ICS and formoterol as rescue medications in mild cases were suggested to reduce the overreliance on SABAs. Encouraging SABA alone-free clinical practice in both outpatient and emergency department settings is also imperative. We present the recommendations for the management of asthma along with proposed regional adaptations of international guidelines for MEA.
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ORIGINAL ARTICLES Top

COVID-19 reinfection: A multicenter retrospective study in Saudi Arabia p. 81
Naila A Shaheen, Rakan Sambas, Maha Alenezi, Naif Khalaf Alharbi, Omar Aldibasi, Mohammad Bosaeed
DOI:10.4103/atm.atm_74_22  
INTRODUCTION: There are limited direct data on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) long-term immune responses and reinfection. This study aimed to evaluate the rate, risk factors, and severity of COVID-19 reinfection. METHODS: This retrospective cohort study included five hospitals across Saudi Arabia. All subjects who were presented or admitted with positive SARS-CoV-2 real-time polymerase chain reaction (RT-PCR) tests were evaluated between March 2020 and August 2021. Reinfection was defined as a patient who was infected followed by clinical recovery, and later became infected again 90 days post first infection. The infection was confirmed with a positive SARS-CoV-2 (RT-PCR). Four hundred and seventeen recovered cases but with no reinfection were included as a control. RESULTS: A total of 35,288 RT-PCR-confirmed COVID-19 patients were observed between March 2020 and August 2021. Based on the case definition, (0.37%) 132 patients had COVID-19 reinfection. The mean age in the reinfected cases was 40.95 ± 19.48 (range 1–87 years); Females were 50.76%. Body mass index was 27.65 ± 6.65 kg/m2; diabetes and hypertension were the most common comorbidities. The first infection showed mild symptoms in 91 (68.94%) patients; and when compared to the control group, comorbidities, severity of infection, and laboratory investigations were not statistically different. Hospitalization at the first infection was higher, but not statistically different when compared to the control group (P = 0.093). CONCLUSION: COVID-19 reinfection is rare and does not carry a higher risk of severe disease. Further studies are required, especially with the continuously newly emerging variants, with the unpredictable risk of reinfection.
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Pathophysiology and rehabilitation management of exercise intolerance in COVID-19 patients p. 87
Arnengsih Nazir, Indra Putera Hasri
DOI:10.4103/atm.atm_357_21  
OBJECTIVE: This review aimed to explore the pathophysiology and rehabilitation management of exercise intolerance in COVID-19 patients. METHODS: We reviewed articles published in 2019-2021 using PubMed, Google Scholar, and CINAHL databases as an electronic database. Data obtained were pathophysiology and rehabilitation management of exercise intolerance in COVID-19 survivors. Types of the article were original articles and systematic or narrative reviews, both published and preprint articles. Articles that were written in English and freely accessible in pdf or HTML format were included. RESULTS: There were 28 articles eligible for this review. Pathophysiology, rehabilitation management, and both pathophysiology and rehabilitation management were explained in 7, 24, and 4 articles, consecutively. DISCUSSION: Exercise intolerance is caused by some pathological processes in the respiratory, cardiovascular, and musculoskeletal systems as a result of systemic inflammation. Fatigue and shortness of breath during the activity were the most common symptom in the early phase of COVID-19 and persisted until the follow-up phase. Hospital admission, especially prolonged use of ventilators and immobilization worsen functional impairment resulting in persistent symptoms. Rehabilitation management begins with a functional assessment consisting of symptom assessment and physical examination of the body systems affected. The goals of rehabilitation management are to increase functional capacity, reduce symptoms, improve the ability to perform daily activities, facilitate social reintegration, and improve quality of life. Exercise is an effective intervention to reach these goals. Several studies recommend breathing, and aerobic exercises, as well as resistance exercises for peripheral and respiratory muscles, to improve symptoms and increase functional capacity.
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Evaluation of risk stratification and adherence to venous thromboembolism prophylaxis among hospitalized obstetric women: Retrospective case file review at East Jeddah Hospital during 2018–2019 p. 94
Ghadeer Mattar, Nada Al Sahafi, Lujain Al Hazmi, Nadia Al Hazmi, Hanaa Elsayed Abozeid, Intessar Sultan
DOI:10.4103/atm.atm_79_21  
BACKGROUND: Venous thromboembolism (VTE) is associated with substantial mortality as well as morbidity and is largely preventable among hospitalized obstetric women. However, thromboprophylaxis is underutilized in most hospitalized patients. OBJECTIVES: To evaluate VTE risk and adherence to local thromboprophylaxis protocol among hospitalized pre- and postnatal women. METHODS: This retrospective study was conducted at East Jeddah Hospital, Jeddah, Saudi Arabia, in 2020. The electronic record database of the hospitalized pregnant Saudi women during the years 2018 and 2019 was reviewed. Based on the local hospital protocol, the risk stratification was reassessed by researchers, and the hospital adherence to the prophylaxis was reviewed separately for antenatal and postnatal women. RESULTS: One thousand and ninety-five electronic records (539 antenatal and 556 postnatal) were reviewed. The postnatal group showed a significantly higher risk compared with an antenatal group (62.2% vs. 11.7%) (P = 0.000). There was a highly significant difference between risk categories assessment by the physicians and the researchers in both groups (P = 0.000). Thromboprophylaxis was overutilized in the low risk (5% heparin and 41.4% heparin and mechanical devices for antenatal and 17.08% heparin and 6.1% heparin and a mechanical device for the postnatal group) and underutilized in intermediate groups (50% no prophylaxis in antenatal and 51.5% mechanical devices in the postnatal group). There was less adherence to documentation in postnatal as compared to antenatal group (83.6% vs. 95%, P = 0.000) for risk documentation and 85.3% versus 91.5% for physician signature (P = 0.001). Thromboprophylaxis was ordered for 21.3% of antenatal (12.2 heparin, 3.5% mechanical, and 5.6% both) and 23.7% of postnatal patients (16.5 heparin, 2% mechanical, and 5.2% both). There were no reported VTE events or bleeding complications. CONCLUSION: There was a considerable VTE risk among hospitalized obstetric patients which peaked during the postnatal period. Physicians showed good compliance to local VTE protocol with no reported VTE events or drug-induced bleeding. However, the implementation of prophylaxis is associated with both under and overutilization. There is a need for increasing the physicians' awareness of optimizing VTE risk assessment and documentation for hospitalized obstetric patients.
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The association of timing of pharmacological prophylaxis and venous thromboembolism in patients with moderate-to-severe traumatic brain injury: A retrospective cohort study p. 102
Hasan M Al-Dorzi, Ghadah Al-Yami, Fatima Al-Daker, Muhannad Q Alqirnas, Moustafa S Alhamadh, Raymond Khan
DOI:10.4103/atm.atm_174_21  
OBJECTIVES: Patients with traumatic brain injury (TBI) have an increased risk for venous thromboembolism (VTE). The current guidelines recommend pharmacologic prophylaxis, but its timing remains unclear. METHODS: In this retrospective cohort study, patients with moderate-to-severe TBI admitted to a tertiary care intensive care unit between 2016 and 2019 were categorized into two groups according to the timing of pharmacologic prophylaxis: early if prophylaxis was given within 72 h from hospital admission and late if after 72 h. RESULTS: Of the 322 patients in the cohort, 46 (14.3%) did not receive pharmacological prophylaxis, mainly due to early brain death; 152 (47.2%) received early pharmacologic prophylaxis and 124 (38.5%) received late prophylaxis. Predictors of late pharmacologic prophylaxis were lower body mass index, intracerebral hemorrhage (odds ratio [OR], 3.361; 95% confidence interval [CI], 1.269–8.904), hemorrhagic contusion (OR, 3.469; 95% CI, 1.039–11.576), and lower platelet count. VTE was diagnosed in 43 patients on a median of 10 days after trauma (Q1, Q3: 5, 15): 6.6% of the early prophylaxis group and 26.6% of the late group (P < 0.001). On multivariable logistic regression analysis, the predictors of VTE were Acute Physiology and Chronic Health Evaluation II score, subarachnoid hemorrhage, and late versus early pharmacologic prophylaxis (OR, 3.858; 95% CI, 1.687–8.825). The late prophylaxis group had higher rate of tracheostomy, longer duration of mechanical ventilation and stay in the hospital, lower discharge Glasgow coma scale, but similar survival, compared with the early group. CONCLUSIONS: Late prophylaxis (>72 h) was associated with higher VTE rate in patients with moderate-to-severe TBI, but not with higher mortality.
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The effectiveness of POST-DISCHARGE telerehabilitation practices in COVID-19 patients: Tele-COVID study-randomized controlled trial p. 110
Esra Pehlivan, İsmail Palalı, Sibel Gayretli Atan, Demet Turan, Halit Çınarka, Erdoğan Çetinkaya
DOI:10.4103/atm.atm_543_21  
AIMS: We aimed to investigate the effectiveness of a telerehabilitation exercise program performed without requiring any special equipment on the physical condition of COVID-19 subjects. SETTINGS AND DESIGN: This was a randomized controlled study. METHODS: This study included subjects with a history of hospitalization with a diagnosis of COVID-19 and discharged within 4 weeks. The subjects were divided into two groups randomly, namely telerehabilitation group (TeleGr, n = 17) or control group (CGr, n = 17). The TeleGr received breathing and range of motion exercises, active cycle of breathing technique, and an aerobic training 3 days a week for 6 weeks, while CGr received an exercise brochure with the same content. Subjects were evaluated using the modified Medical Research Council (mMRC) dyspnea score for dyspnea, 30 s sit-to-stand test (30STS) and short physical performance battery (SPPB) to determine their physical status, Saint George Respiratory Questionnaire (SGRQ) to assess quality of their life, and Beck Depression Inventory. All evaluations were carried out at home using videoconferencing. RESULTS: A significant improvement was observed in TelerGr in terms of mMRC (P= 0.035), 30STS (P= 0.005), 5 sit-to-stand time which is one of the subtests of SPPB (P = 0.039) and SGRQ scores. Significant improvement was observed only in the pain score in the CGr (P = 0.039). There was a statistically significant difference between the groups in SGRQ activity (P = 0.035) and total (P = 0.042) scores. In addition, more symptomatic improvement was found in TeleGr. CONCLUSION: Telerehabilitation exercise program with less technical equipment is a good alternative treatment method for COVID-19 subjects, which improves the quality of life and symptomatic status of subjects. Clinical Trial Registration Number: nct04402983
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Obstructive sleep apnea in patients with severe asthma: Prevalence and association between severity and asthma control p. 118
Fatema Al-Lawati, Saif M Al-Mubaihsi, B Jayakrishnan, Sayed Rizvi, Mohammed A Al-Abri
DOI:10.4103/atm.atm_375_21  
INTRODUCTION: Asthma and obstructive sleep apnea (OSA) are common respiratory disorders that can coexist and cause sleep disturbances. The strength of this association and the impact of OSA on asthma severity and control remain unclear. The study aims to estimate the prevalence of OSA in patients with severe asthma in Oman and to examine whether the severity of OSA contributed to the level of asthma control. METHODS: Adult patients with confirmed diagnosis of severe asthma who attended the respiratory clinic in a tertiary hospital in Oman over a period of 19 months were enrolled in the study. Eligible participants were screened by asthma control test (ACT) and Berlin questionnaire (BQ). Patients with high risk for OSA were subjected further to level 3 sleep study. The prevalence of OSA in patients with severe asthma and the associations between the severity of OSA and asthma control were calculated. RESULTS: We identified 312 adult asthma patients on Global Initiative for Asthma step 4 or 5 management out of 550 who were screened. The mean age of the study population was 56.59 ± 12.40 years and the mean body mass index (BMI) 40.30 ± 12.24 kg/m2. The prevalence of OSA in asthma patients with severe asthma was found to be 32.4%. Out of the 138 well-controlled asthma patients (ACT ≥20), 35 had high risk of OSA based on BQ, and 32 were confirmed to have OSA (23%). Of the 174 uncontrolled patients, 80 patients had high risk of OSA and 69 patients were confirmed to have OSA (39.65%). Severe OSA was seen in 63.8% and 9.4% in uncontrolled and controlled asthma patients, respectively (P = 0.002). The median respiratory event index in the uncontrolled group was 43, and it was significantly higher than 12.5 in the controlled group (P < 0.001). CONCLUSIONS: The prevalence of OSA was high (32.37%) in patients with severe asthma. Uncontrolled severe asthma was significantly associated with severe OSA.
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Diagnostic value of bronchoscopy in sputum-negative pulmonary tuberculosis patients and its correlation with clinicoradiological features p. 124
Sadia Imtiaz, Enas Mansour Batubara
DOI:10.4103/atm.atm_487_21  
CONTEXT: Tuberculosis (TB) remains endemic in Saudi Arabia. Little local data have been reported on bronchoscopic evaluation of sputum-negative pulmonary TB patients, which poses a significant diagnostic and therapeutic challenge. AIMS: To determine the diagnostic value of bronchoscopy and bronchoalveolar lavage (BAL) and its correlation with clinical and radiological features in sputum-negative, culture-confirmed pulmonary TB patients. METHODS: We performed a retrospective analysis of patients with definite or probable pulmonary TB with overall negative (smear and/or polymerase chain reaction [PCR]) or scanty sputum that had undergone bronchoscopy with BAL over a period of 5 years. Patients' symptoms, radiological features, lung lobe lavaged, BAL acid-fast bacilli (AFB) stain, Mycobacterium TB (MTB)-PCR, and mycobacterial cultures were analyzed. Mycobacterial cultures (either sputum or BAL) were used as a reference standard. RESULTS: Out of 154 patients, 49 (32%) were overall sputum negative and underwent a diagnostic bronchoscopy. Dry cough and fever were the most common symptoms. Uncontrolled diabetes mellitus was the most frequent comorbidity identified in 15 (31%) patients. Fifty-nine percent of the patients had diffuse lung infiltrates, with consolidation being the most common abnormality (41%), followed by cavitation (39%). Right upper lobe was the most frequent lung lobe lavaged (31%), while transbronchial lung biopsies (TBLB) were obtained in 21 (43%). BAL mycobacterial culture and MTB PCR were positive in 35 (71%) and 23 (47%) patients, respectively. Combined BAL MTB PCR and TBLB provided rapid diagnosis in 28 (57%) patients. CONCLUSIONS: An overall diagnostic yield of 90% was achieved with combined use of BAL MTB PCR, culture, and histopathology. Upper lobe lavage and presence of cavities on chest imaging had a higher diagnostic yield.
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CASE REPORT Top

Difficulties in the treatment of an infant survivor with inherited surfactant protein-B deficiency in Tunisia p. 132
Samia Hamouda, Ines Trabelsi, Alix de Becdelièvre, Khadija Boussetta
DOI:10.4103/atm.atm_445_21  
A female-term neonate showed a severe respiratory distress syndrome (RDS) at hour 3 of life requiring her transfer to intensive care. She was intubated and started on assist-control mechanical ventilation associated with inhaled nitric oxide then high-frequency oscillation ventilation at day 12. Chest X-ray was gradually deteriorating. Chest computed tomography (CT) scan revealed diffuse interstitial lung disease. Flexible bronchoscopy excluded pulmonary alveolar proteinosis. The genetics study confirmed surfactant protein-B (SP-B) deficiency caused by the novel homozygous c.770T>C, p.Leu257Pro mutation in the SFTPB gene (NM_000542.5). Methylprednisolone pulse therapy was administered from day 20. As the infant worsened, azithromycin, sildenafil, and inhaled steroids were added at the age of 6 months and azathioprine at the age of 10 months. At the age of 12 months, chest CT showed diffuse “crazy-paving.” The infant died of respiratory failure at the age of 13 months. Unexplained neonatal RDS should raise the suspicion of SP-B disease. This novel mutation could be part of the mutations allowing partial SP-B production result in prolonged survival. Lung transplant in infants, unavailable in numerous countries, remains the unique way to reverse the fatal outcome.
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