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.

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Background: Respiratory care (RC) is an allied health profession that involves assessing and treating patients who have pulmonary diseases. Research indicates that respiratory therapists' (RT's) involvement in caring for patients with respiratory disorders improves important outcome measures. In Kingdome of Saudi Arabia (KSA), RC has been practiced by RTs for more than 30 years. Objective: We sought to investigate the status of the RC workforce in Saudi Arabia in terms of demographic distribution, number, education, and RC service coverage. Methods: We used a specially designed survey to collect data. A list of 411 working hospitals in KSA was obtained. All hospitals were contacted to inquire if RC is practiced by RTs. Data were collected from hospitals that employ RTs. Results: Only 88 hospitals, 21.4% of total hospitals in the country, have RTs. Out of the 244 Ministry of Health (MOH) hospitals, only 31 hospitals (12.7%) employ RTs. There are 1,477 active RTs in KSA. Twenty-five percent of them, or 371, are Saudis. The majority of the RT workforce (60%) work for non-MOH government hospitals, and almost half the total RTs work in Riyadh province. About 60% of RTs work in critical care settings. RC coverage of critical care was 44.5% of ideal. The overall RT-to-ICU bed ratio was 1:11. The ratio was 1:9 for non-MOH government hospitals, and 1:20 for MOH hospitals. Conclusions: We report the first insightful data on RC workforce in KSA. These data should be used by educational institutions and health policy makers to plan better RC coverage in the country.

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Background: Recent trials involving pirfenidone suggest a beneficial effect in the treatment of idiopathic pulmonary fibrosis (IPF). Objective: To report on the efficacy and safety of pirfenidone in the treatment of patients with IPF, at a tertiary care hospital in Saudi Arabia. Methods: The study included 58 patients with IPF who were evaluated from March 2012 to March 2013. During the study period, 33 patients received pirfenidone, and the remaining patients (n = 25) served as a control group. Baseline clinical characteristics, physiological parameters and the results of a 36-Item Short Form Health Survey (SF-36) were compared between the groups. Furthermore, we compared changes in forced vital capacity (FVC), diffusion capacity of the lung for carbon monoxide (DLco), six-minute walk distance (6MWD) and SF-36 for both groups during follow-up. The last follow-up period ended in January 2014. Results: There were no significant differences in baseline clinical characteristics between the groups. Furthermore, we found no differences in FVC, DLco and SF-36 during follow-up (median, 12 months). However, patients receiving pirfenidone treatment were less likely to experience reductions in 6MWD compared with the control group (13% vs. 52%, respectively; P = 0.001). Although adverse events were more frequently reported by the pirfenidone group compared with the control group (85 vs. 56%, respectively; P = 0.015), these patients did not require discontinuation of treatment. Conclusion: Pirfenidone treatment preserves functional capacity, as reflected by the 6MWD. Adverse events associated with pirfenidone treatment were generally well tolerated by the patients.

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Introduction: Inferior vena cava collapsibility index (IVC-CI) has been shown to correlate with both clinical and invasive assessment of intravascular volume status, but has important limitations such as the requirement for advanced sonographic skills, the degree of difficulty in obtaining those skills, and often challenging visualization of the IVC in the postoperative patient. The current study aims to explore the potential for using femoral (FV) or internal jugular (IJV) vein collapsibility as alternative sonographic options in the absence of adequate IVC visualization. Methods: A prospective, observational study comparing IVC-CI and Fem- and/or IJV-CI was performed in two intensive care units (ICU) between January 2012 and April 2014. Concurrent M-mode measurements of IVC-CI and FV- and/or IJV-CI were collected during each sonographic session. Measurements of IVC were obtained using standard technique. IJV-CI and FV-CI were measured using high-frequency, linear array ultrasound probe placed in the corresponding anatomic areas. Paired data were analyzed using coefficient of correlation/determination and Bland-Altman determination of measurement bias. Results: We performed paired ultrasound examination of IVC-IJV (n = 39) and IVC-FV (n = 22), in 40 patients (mean age 54.1; 40% women). Both FV-CI and IJV-CI scans took less time to complete than IVC-CI scans (both, P < 0.02). Correlations between IVC-CI/FV-CI (R ² = 0.41) and IVC-CI/IJV-CI (R ² = 0.38) were weak. There was a mean -3.5% measurement bias between IVC-CI and IJV-CI, with trend toward overestimation for IJV-CI with increasing collapsibility. In contrast, FV-CI underestimated collapsibility by approximately 3.8% across the measured collapsibility range. Conclusion: Despite small measurement biases, correlations between IVC-CI and FV-/IJV-CI are weak. These results indicate that IJ-CI and FV-CI should not be used as a primary intravascular volume assessment tool for clinical decision support in the ICU. The authors propose that IJV-CI and FV-CI be reserved for clinical scenarios where sonographic acquisition of both IVC-CI or subclavian collapsibility are not feasible, especially when trended over time. Sonographers should be aware that IJV-CI tends to overestimate collapsibility when compared to IVC-CI, and FV-CI tends to underestimates collapsibility relative to IVC-CI.

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Non-invasive ventilation (NIV) has been widely supported in the past two decades as an effective application in avoiding the need for endotracheal intubation (ETI) and reducing associated mortality in acute hypoxemic respiratory failure (AHRF) patients. However, the efficacy of NIV in AHRF patients, non-related to chronic obstructive pulmonary disease (COPD) and trauma is still controversial in the field of medical research. This retrospective study aimed to evaluate the efficacy of NIV as an adjunctive therapy in non-COPD and non-traumatic AHRF patients. Data of 11 randomized control trials (RCTs), which were conducted between 1990 and 2010 to determine the efficacy of NIV in non-COPD and non-traumatic AHRF patients, were reviewed from the PUBMED, MEDLINE, Cochrane Library, and EMBASE databases. Parameters monitored in this study included the ETI rate, fatal complications, mortality rate of patients, and their ICU and hospital duration of stay. Overall results showed a statistically significant decrease in the rate of ETI, mortality, and fatal complications along with reduced ICU and hospital length of stay in non-COPD and non-trauma AHRF patients of various etiologies. This systematic review suggests that non-COPD and non-trauma AHRF patients can potentially benefit from NIV as compared with conventional treatment methods. Observations from various cohort studies, observational studies, and previously published literature advocate on the efficacy of NIV for treating non-COPD and non-traumatic AHRF patients. However, considering the diversity of studied populations, further studies and more specific trials on less heterogeneous AHRF patient groups are needed to focus on this aspect.

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Objectives: The effects of first-line chemotherapy on overall survival (OS) might be confounded by subsequent therapies in patients with small cell lung cancer (SCLC). We examined whether progression-free survival (PFS), post-progression survival (PPS), and tumor response could be valid surrogate endpoints for OS after first-line chemotherapies for patients with extensive SCLC using individual-level data. Methods: Between September 2002 and November 2012, we analyzed 49 cases of patients with extensive SCLC who were treated with cisplatin and irinotecan as first-line chemotherapy. The relationships of PFS, PPS, and tumor response with OS were analyzed at the individual level. Results: Spearman rank correlation analysis and linear regression analysis showed that PPS was strongly correlated with OS (r = 0.97, p < 0.05, R ² = 0.94), PFS was moderately correlated with OS (r = 0.58, p < 0.05, R ² = 0.24), and tumor shrinkage was weakly correlated with OS (r = 0.37, p < 0.05, R ² = 0.13). The best response to second-line treatment, and the number of regimens employed after progression beyond first-line chemotherapy were both significantly associated with PPS ( p ≤ 0.05). Conclusion: PPS is a potential surrogate for OS in patients with extensive SCLC. Our findings also suggest that subsequent treatment after disease progression following first-line chemotherapy may greatly influence OS.

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Cystic fibrosis (CF) and apparent mineralocorticoid excess (AME) syndrome are both autosomal recessive disorders that result from mutations of specific identified genes for each condition. CF is caused by defects in the Cystic fibrosis trans membrane conductance regulator (CFTR) gene which encodes for a protein that functions as a chloride channel and regulates the flow of other ions across the apical surface of epithelial cells. AME is due to the deficiency of 11β-hydroxysteroid dehydrogenase type 2 enzyme (11βHSD2), which is responsible for the peripheral inactivation of cortisol to cortisone. Cortisol excess stimulates the mineralocoritoid receptors (MR) resulting in intense sodium retention, hypokalemia and hypertension. We report on a consanguineous Arab family, in which two sibs inherited both CF and AME. Gene testing for AME revealed previously unreported mutation in the 11βHSD2 gene. This report draws attention to the importance of recognizing the possibility of two recessive disorders in the same child in complex consanguineous families. Moreover, it provides a unique opportunity to highlight the implications of the coexistence of two genetic disorders on patient care and genetic counseling of the family.

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Aim: In this study, we aimed to investigate the effect of written informed consent and comprehensive multimedia information on the anxiety level of patients, consumption of sedatives, difficulties during bronchoscopy, complications and duration of procedure. Methods: 150 patients undergoing bronchoscopy were included to this study. They were randomized into two groups Multimedia information group (MIG, n = 75) and written-informed consent group (WICG, n = 75)). Signed written informed consent was obtained from all patients. Patients in MIG group watched comprehensive multimedia presentation. State anxiety scores of all patients were evaluated with State and Trait anxiety inventory (STAI-S). Results: STAI-S score of patients in MIG (40.31 ± 8.08) was lower than patients in WICG (44.29 ± 9.62) (P = 0.007). Satisfaction level was higher in MIG (P = 0.001). Statistically higher difficulties during "passage through vocal cords" and "interventions during bronchoscopy" were present in WICG group (P = 0.013 and P = 0.043, respectively). Total midazolam dose during bronchoscopy, and duration of bronchoscopy were statistically lower in MIG patients (P < 0.001 and P = 0.045, respectively). Difficulties during "waiting period", "passage through nasal/oral route", "applications of local anesthesia" and "complication frequency" were similar in both groups. Conclusion: Besides reducing the state anxiety, multimedia information can reduce the dose of sedation, shorten the processing duration and reduce the difficulties during bronchoscopy.

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Objective: Major sand storms are frequent in the Middle East. This study aims to investigate the role of air particulate matter (PM) level in acute asthma in children in Riyadh, Saudi Arabia. Methods: An aerosol spectrometer was used to evaluate PM < 10μm in diameter (PM ₁₀ ) and PM < 2.5 μm in diameter (PM _2.5 ) concentrations in the air every 30 minutes throughout February and March 2012 in Riyadh. Data on children 2-12 years of age presenting to the emergency department of a major children's hospital with acute asthma during the same period were collected including their acute asthma severity score. Results: The median with interquartile range (IQR) levels of PM ₁₀ and PM _2.5 were 454 μg/m ³ (309,864) and 108 μg/m ³ (72,192) respectively. There was no correlation between the average daily PM ₁₀ levels and the average number of children presenting with acute asthma per day (r = -0.14, P = 0.45), their daily asthma score (r = 0.014, P = 0.94), or admission rate ( r= -0.08, P = 0.65). This was also true for average daily PM _2.5 levels. In addition, there was no difference in these variables between days with PM ₁₀ >1000 μg/m ³ , representing major sand storms, plus the following 5 days and other days with PM ₁₀ < 1000 μg/m ³ . Conclusion: Sand storms, even major ones, had no significant impact on acute asthma exacerbations in children in Riyadh, Saudi Arabia. The very high levels of PM, however, deserve further studying especially of their long-term effects.

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Background and Aim: We aimed to validate the Turkish version of Berlin Questionnaire (BQ) and developped a BQ-gender (BQ-G) form by adding gender component. We aimed to compare the two forms in defining patients with moderate to severe obstructive sleep apnea (OSA) in sleep clinics. Methods: Four hundred and eighty five consecutive patients, refered to our sleep clinic for snoring, witnessed apnea and/or excessive daytime sleepiness were enrolled to the study. All patients underwent in-laboratory polysomnography (PSG). Patients with sleep efficiency less than 40% and total sleep time less than 4 hours, chronic anxiolitic/sedative drug usage, respiratory tract infection within past two weeks were excluded from the study. All the patients fulfilled BQ. The test and retest for BQ were applied in 15-day interval in 30 patients. Results: Totally 433 patients were enrolled to the study (285 male, 148 female).The mean age of the patients was 47,5 ± 10.5 (21-79). 180 patients (41.6%) had apnea-hypopnea index (AHI) ≤ 15, while 253 patients (58,4%) had AHI > 15. The κ value was 48–94 and the the truth value was 69-94% for the test-retest procedure. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and area under the curve AUC were 84.2%, 31.7%, 48.7%, 63.4%, and 0.579 in order for BQ and 79.9 %, 51.7%, 63.2% , 69.6%, and 0.652 for BQ-G. Conclusion: The results showed that BQ-G is relatively better than BQ in determining moderate to severe OSA in sleep clinics where most of the patients are sleep apneic but both of the tests were found to have insufficient validities in defining moderate to severe OSA in sleep clinics.

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Bronchobiliary fistula (BBF) can complicate most hepatic pathologies. This is a challenging group of patients, especially when surgery is precluded. The bronchoscopic application of silicon spigots is a recognized technique for the treatment of massive hemoptysis and the management of patients with bronchopleural fistula following lung resection. Their role in the treatment of BBF has never been described. In this paper we report the successful embolization using silicon spigots in two patients with BBF secondary to malignant disease, when all surgical options were exhausted.

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Introduction: Conventional transbronchial needle aspiration (C-TBNA) is a minimally invasive, safe, and cost-effective technique in evaluating mediastinal lymphadenopathy. Previously we reported that the skills for C-TBNA can be acquired from the books. We studied the learning curve for C-TBNA for a single bronchoscopist at a tertiary-care center where ultrasound technology remains difficult to acquire . Methods: We prospectively collected results of the first 99 consecutively performed C-TBNA between December 2009 and 2013. Patients were divided into 3 groups: (I): First 33, (II): Next 33 and (III): Last 33. Results were categorized as malignant, non-malignant or non-diagnostic. Diagnostic yield (DY), sensitivity (SEN), specificity (SPE), positive and negative predictive values (PPV, NPV), and accuracy (ACC) were calculated to learn the learning curve for C-TBNA. Results: Total 99 patients (M:F = 62:37), mean age 58.2 ± 11.5 years, mean LN diameter 26.9 ± 9.8 mm underwent C-TBNA. Sixty-nine patients had lymph nodes (LNs) >20 mm in diameter. Final diagnoses were established by C-TBNA in 44 (yield 44.4%), mediastinoscopy 47, transthoracic needle aspiration 5, endobronchial biopsy 2 and peripheral LN biopsy 1. C-TBNA was exclusively diagnostic in 35.4%. Group I: DY: 42.4%, 64.7% in malignancies, 19% in benign conditions (P = 0.008). SEN, SPE, PPV, NPV, ACC = 70%, 100%, 100%, 66.6%, 78.7%, respectively. Group II: DY: 54.5% (36.4% exclusive), 88.2% in malignancies and 19% benign conditions (P = 0.000). SEN, SPE, PPV, NPV, ACC=72%, 100%, 100%, 53.3%, 78.7%, respectively. Group III: DY: 36.3% (27% exclusive), 100% in malignancies and 16% in benign conditions. SEN, SPE, PPV, NPV, ACC = 92.3%, 100%, 100%, 95.2%, 97%, respectively. No difference was found in relation to LN size or location and TBNA yield. Conclusion: C-TBNA can be easily learned and the proficiency can be attained with <66 procedures. In selected patients, its exclusivity could exceed 35%.

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