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
January-March 2023
Volume 18 | Issue 1
Page Nos. 1-51

Online since Wednesday, January 25, 2023

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The implications of Vitamin E acetate in E-cigarette, or vaping, product use-associated lung injury p. 1
Brian Soto, Louis Costanzo, Anoop Puskoor, Nada Akkari, Patrick Geraghty
In the summer of 2019, a cluster of cases were observed with users of battery-operated or superheating devices presenting with multiple symptoms, such as dyspnea, cough, fever, constitutional symptoms, gastrointestinal upset, and hemoptysis, that is now termed e-cigarette, or vaping, product use-associated lung injury (EVALI). The Centers for Disease Control and Prevention reported 2807 cases within the USA leading to at least 68 deaths as of February 18, 2020. The heterogeneous presentations of EVALI make diagnosis and treatment difficult; however, treatment focused on identifying and removal of the noxious substance and providing supportive care. Vitamin E acetate (VEA) is a likely cause of this lung injury, and others have reported other components to play a possible role, such as nicotine and vegetable glycerin/propylene glycol. EVALI is usually observed in adolescents, with a history of vaping product usage within 90 days typically containing tetrahydrocannabinol, and presenting on chest radiograph with pulmonary infiltrates or computed tomography scan with ground-glass opacities. Diagnosis requires a high degree of suspicion to diagnose and exclusion of other possible causes of lung disease. Here, we review the current literature to detail the major factors contributing to EVALI and primarily discuss the potential role of VEA in EVALI. We will also briefly discuss other constituents other than just VEA, as a small number of EVALI cases are reported without the detection of VEA, but with the same clinical diagnosis.
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General rehabilitation for the Post-COVID-19 condition: A narrative review p. 10
Dian Marta Sari, Laurentia Cindy Gani Wijaya
COVID-19 significantly impacts the acute phase or the period after being infected by severe acute respiratory syndrome coronavirus-2. Studies have shown it has affected multiorgan and needs continuous care by a multidisciplinary team. Nowadays, guidance is required to assist the recovery process of survivors who reported at least one symptom as a residual effect. This study aims to describe the rehabilitation management of post-COVID-19 conditions. As the number of survivors seems to be increasing, it is expected that COVID-19 survivors will recover through a holistic approach by all physicians. Comprehensive rehabilitation for long COVID or COVID-19-related illnesses includes exercising, nutrition, education, managing voice, breathlessness, neurocognitive problems, mental health, feeding problems, and daily activities. Specific recommendations have already been published to support rehabilitation for survivors in every targeted organ. Supportive care, especially rehabilitation programs, is recently an urgent knowledge in this pandemic.
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Measurement of the awareness of venous thromboembolism in the Saudi population p. 15
Ali Alaklabi, Shouq Mohammed AlNujaim, Sarah Mohammed Alghaihab, Sadeem Ahmed AlDakhil, Obeid Mohammed AlKethami, Rajkumar Rajendram
BACKGROUND: Venous thromboembolism (VTE) causes significant morbidity and mortality. International studies have suggested poor public awareness of VTE, with a few data from Saudi Arabia. The aim of this study was to investigate the knowledge and awareness of VTE in the Saudi population. Awareness of other important diseases was also investigated to allow contextualization. METHODS: A cross-sectional survey study was conducted throughout Saudi Arabia from April to June 2021. A nonprobability, purposive, social media-driven, snowballing sampling technique was used to distribute a validated online questionnaire to Saudi adults (aged over 18 years) from the general population. RESULTS: Of 1226 respondents, 214 were excluded as they were health-care professionals. The majority of the participants were unaware and unconcerned about VTE. They were more aware of other medical conditions such as hypertension. Immobility and old age were frequently recognized as risk factors for VTE. While less than half of the participants were aware that thrombosis is the cause of VTE, most participants correctly identified leg pain and tenderness as symptoms of deep venous thrombosis. The majority of the participants identified chest pain and breathlessness as symptoms of pulmonary embolism. However, leg paralysis and slow, shallow breathing were frequently identified as symptoms of VTE. The majority of subjects disagreed with the statement, "having a blood clot is not considered a medical emergency." Awareness of VTE varied significantly with age. CONCLUSION: In Saudi Arabia, the public awareness of VTE is poor. To improve outcomes, public health initiatives must increase awareness, introduce preventive measures, encourage early diagnosis, and ensure compliance with treatment.
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Increased airway resistance among exclusive waterpipe smokers detected using impulse oscillometry p. 23
Hassan A Chami, Nourhan Houjeij, Maha Makki, Lina Itani, Hani Tamim, Ahmad Al Mulla, Bartolome Celli, Salah Zeineldine
INTRODUCTION: Waterpipe smoking is increasing in popularity, yet the evidence implicating waterpipe smoking in lung disease is limited. We hypothesized that impulse oscillometry (IOS) would detect airway abnormalities in waterpipe smokers (WPS). METHODS: We studied 210 participants, 40 years or older, from the community, of whom 92 were exclusive WPS and 118 were never-smokers. Waterpipe smoking history was assessed using a validated questionnaire. All participants underwent spirometry, and IOS and absolute and percentage predicted results (for age, sex, height, and weight) were compared between WPS and nonsmokers. The association of IOS parameters with waterpipe smoking duration and extent (waterpipe smoked/day * smoking duration) was evaluated using linear regression. RESULTS: WPS smoked on average 1.8 ± 1.2 waterpipes/day, over an average duration of 23.3 ± 39.8 years. WPS and nonsmokers were largely asymptomatic and had similar age, body mass index, sex distribution, and spirometric values. Nevertheless, WPS had higher IOS measured resistance at 5Hz compared to nonsmokers, (0.53 ± 0.2 vs. 0.48 ± 0.2 kPa/L/s, P = 0.03) and higher percentage-predicted resistance (124.5 ± 36.3 vs. 115.7% ± 35.6%, P = 0.04). Waterpipe smoking duration was also associated with resistance (β = 0.04 kPa/L/s/year, P = 0.01) and with percentage-predicted resistance (β = 0.05/year, P = 0.02). Waterpipe smoking extent was associated with resistance (β = 0.009 kPa/L/s/waterpipe-year, P = 0.04), while the association with percentage-predicted resistance was near significance (β = 0.009/waterpipe-year, P = 0.07). CONCLUSIONS: Waterpipe smoking is associated with increased airway resistance assessed by IOS but not by spirometry in largely asymptomatic individuals from the community.
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Optimal positive airway pressure requirement and polysomnography indices of obstructive sleep apnea severity in the Saudi population p. 31
Ahmad A Bamagoos, Shahad A Alshaynawi, Atheer S Gari, Atheer M Badawi, Mudhawi H Alhiniah, Asma A Alshahrani, Renad R Rajab, Reem K Bahaj, Faris Alhejaili, Siraj O Wali
CONTEXT: Positive airway pressure (PAP) is the first-line therapy for obstructive sleep apnea (OSA). Overnight PAP titration for determining optimal PAP requirements is expensive and often inconvenient. Prediction of optimal PAP requirements from diagnostic polysomnography via mathematical equations is possible but variable across populations. AIMS: We aimed to (1) determine the optimal PAP requirement, (2) determine differences in optimal PAP requirements across OSA severity groups, (3) determine the relationship between optimal PAP requirement and diagnostic polysomnography measurements of OSA severity, and (4) develop a pilot equation to predict the optimal PAP requirement from diagnostic polysomnography in a sample from the Saudi population. METHODS: We analyzed records pertaining to adult OSA patients (n = 215; 63% of males) who underwent standardized diagnostic and titration polysomnography in our sleep laboratory between 2015 and 2019. Demographic, anthropometric, and clinical information were also collected for the analysis. Inferential statistics were performed for comparisons between diagnostic and titration studies and between OSA severity groups. Regression analyses were also performed to determine the potential predictors of optimal PAP requirements. Data were presented as the mean (± standard deviation) or median (25th–75th quartiles) according to normality. RESULTS: The median optimal PAP requirement was 13 (9–17) cmH2O. The optimal PAP requirement was significantly greater for male versus female participants (14 [10–17] vs. 12 [8–16] cmH2O) and for participants with severe OSA (16 [12–20] cmH2O, n = 119) versus those with moderate (11 [8–14] cmH2O, n = 63) or mild (9 [7–12] cmH2O, n = 33) OSA. When combined, nadir oxygen saturation, oxygen desaturation index, and arousal index could be used to predict the optimal PAP requirement (R2 = 0.39, F = 34.0, P < 0.001). CONCLUSIONS: The optimal PAP requirement in the Saudi population is relatively high and directly correlated with OSA severity. Diagnostic polysomnography measurements of OSA severity predicted the optimal PAP requirement in this sample. Prospective validation is warranted.
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Application of single-port laparoscopic retrograde gastric mobilization during McKeown esophagectomy for esophageal cancer p. 39
Bo Liu, Xu Li, Min-Jie Yu, Jin-Bao Xie, Guo-Liang Liao, Ming-Lian Qiu
BACKGROUND: As a novel alternative to the conventional minimally invasive esophagectomy (MIE) to treat esophageal cancer, single-port laparoscopic retrograde three-step gastric mobilization (SLRM) for esophageal reconstruction during MIE to treat esophageal cancer was attempted in our department. The aim of the present study was to explore the preliminary clinical outcomes and feasibility of this innovative surgery. METHODS: From March 2020 to November 2021, patients undergoing SLRM combined with four-port thoracoscopic McKeown esophagectomy for their esophageal cancers were reviewed. Gastric mobilization with abdominal lymph node dissection was performed through SLRM. The clinical characteristics and short-term outcomes were analyzed retrospectively. RESULTS: A total of 120 patients underwent R0 resection without conversion to open surgery. The mean times needed for the thoracic part, abdominal part, and total operation were 43 ± 6 min, 60 ± 18 min, and 230 ± 20 min, respectively. The numbers of mediastinal and abdominal lymph nodes harvested were 13.2 ± 2.7 and 10.2 ± 2.5, respectively. Postoperative pneumonia was encountered in 10 (8.3%) patients. Anastomotic leakage occurred in 3 (2.5%) cases. Temporary vocal cord paralysis was reported in 20 (16.6%) cases. The mean length of hospital stay was 8.5 ± 4.6 days. CONCLUSIONS: The SLRM is a technically feasible and safe treatment for patients with esophageal cancer. It can be considered an alternative method for patients, especially for the ones with obesity and gastric distension.
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Nintedanib and pirfenidone for idiopathic pulmonary fibrosis in King Abdulaziz Medical City, Riyadh: Real-life data p. 45
Mohammed Ayaz Khan, Nahed Sherbini, Sami Alyami, Abdullah Al-Harbi, Majed Al-Ghamdi, Suliman Alrajhi, Rajkumar Rajendram, Hamdan Al-Jahdali
BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a chronic progressive age-related lung disease causing relentless fibrosis of the lung parenchyma. Currently, pirfenidone and nintedanib are the two antifibrotic drugs, approved for the treatment of IPF. Both are shown to slow progression by preserving lung functions from rapid decline compared to a placebo. We are reporting a real-life patient experience using these two antifibrotic medications (AFMs) in our tertiary care hospital. METHODS: A retrospective cohort study was conducted for all IPF cases diagnosed in multidisciplinary meetings between 2015 and 2020 at KAMC, Riyadh (Saudi Arabia). We are reporting patients' demographics, lung function, survival, tolerance, side effects, or death in patients taking AFMs. RESULTS: A total of 81 cases were identified. The majority of patients aged 67 years (68%) were men with a median age of 68 years. Late presentation, severe disease, and definite usual interstitial pneumonia patterns were reported in 60% of our patients. The average number of hospital admissions before starting treatment was 1 (range: 0–3) in the nintedanib group and 1.4 (range: 1.2–5) in the pirfenidone group. There was an increase in the number of hospital admissions in the group started on pirfenidone 1.7 (range: 1.9–8) compared to nintedanib 0.5 (range: 0–3), P = 0.001. The observed mortality outcome in this cohort was 4 (11%) and 12 (27%) for nintedanib and pirfenidone, respectively. The predominant side effects were gastrointestinal symptoms for both the groups 18 (22%). CONCLUSIONS: Pirfenidone and nintedanib are the available approved antifibrotic agents used for many years to treat IPF patients. Real-life data showed better tolerability than reported in the West, good compliance, and a manageable side effect profile in this group of elderly and severe IPF patients.
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