Background: Majority of our computed tomography-pulmonary angiography (CTPA) scans report negative findings. We hypothesized that suboptimal reliance on diagnostic algorithms contributes to apparent overuse of this test. Methods: A retrospective review was performed on 2031 CTPA cases in a large hospital system. Investigators retrospectively calculated pretest probability (PTP). Use of CTPA was considered as inappropriate when it was ordered for patients with low PTP without checking D-dimer (DD) or following negative DD. Results: Among the 2031 cases, pulmonary embolism (PE) was found in 7.4% (151 cases). About 1784 patients (88%) were considered “PE unlikely” based on Wells score. Out of those patients, 1084 cases (61%) did not have DD test prior to CTPA. In addition, 78 patients with negative DD underwent unnecessary CTPA; none of them had PE. Conclusions: The suboptimal implementation of PTP assessment tools can result in the overuse of CTPA, contributing to ineffective utilization of hospital resources, increased cost, and potential harm to patients.

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Dasatinib is a drug for treatment of oncogene fusion protein BCR-ABL-positive chronic myeloid leukemia and Philadelphia chromosome-positive acute lymphoblastic leukemia resistant/intolerant to imatinib. Pleural effusion (PE) is a common adverse effect, and in this context, we present four cases seen due to this cause. One of them is a chylothorax. The PE grade is variable, and the physiopathology is not well established, although a block in T-lymphocyte function or inhibition of platelet-derived growth factor receptor-β is suggested being involved. The PE is generally a lymphocyte-predominant exudate, but can also present as chylothorax. Several factors have been associated with its appearance, particularly the administration in two daily doses. Low grade (1–2) PEs usually respond well to interrupt the treatment while those of higher grade may also require therapeutic thoracentesis and corticosteroids. There are currently no firm guidelines that establish when to resort to one form of treatment or another.

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Background: There is a lack of consensus regarding second-line therapy in children with acute asthma who fail to the standard therapy. Ketamine had bronchodilator property and may be useful in the treatment of acute asthma. Objective: The objective of this study was to evaluate the efficacy and safety of ketamine as compared to aminophylline in children with acute asthma who respond poorly to the standard therapy. Methods: This randomized controlled trial included patients with acute asthma having Pediatric Respiratory Assessment Measure (PRAM) score ≥5 at 2 h of standard therapy. The enrolled patients received either intravenous (IV) ketamine or IV aminophylline. Primary outcome measure was change in PRAM score at the end of intervention. Secondary outcome measures included adverse effects, change in PO₂and PCO₂, need for mechanical ventilation, and duration of hospital stay. Results: The trial included 24 patients each in ketamine and aminophylline groups. The baseline parameters were similar between the groups. The primary outcome was similar in both the groups with a change in PRAM score of 4.00 ± 1.25 and 4.17 ± 1.68 (P = 0.699) in ketamine and aminophylline groups, respectively. The secondary outcomes were not different between the groups. Conclusion: Ketamine and aminophylline were equally effective for children with acute asthma who responded poorly to the standard therapy.

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Aim: The aim of this study was to investigate the alterations of pulmonary function tests (PFTs) and their relationship with disease activity in inflammatory bowel diseases (IBDs). Methods: Sixty-four IBD patients (31 Crohn's disease [CD] and 33 ulcerative colitis [UC]) and thirty healthy individuals (controls) were studied with regard to the following parameters of PFTs: Forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), their ratio, mid-forced expiratory flow of 25–75% (FEF 25–75), residual volume, total lung capacity, and diffusing capacity of the lung for carbon monoxide (DLCO). The disease activity was calculated using the Crohn's Disease Activity Index for CD and Mayo Clinic Score for UC. Correlation analysis was performed between disease activity and sputum cytology and PFTs. Results: Nineteen of the 31 CD patients (61.29%) and 17 of the 33 UC patients (51.52%) but none of the controls showed at least one abnormal PFTs (P < 0.05). Compared with controls, both CD and UC patients exhibited a significant reduction in FEV1 (P < 0.05), FVC (P < 0.05), FEF 25–75 (P < 0.05), and DLCO (P < 0.05). The majority with decreased measurements of PFTs were in the active phase of diseases (P < 0.05). IBD activity scores correlated negatively with some parameters of PFTs and positively with lymphocytosis and eosinophilia of sputum (P < 0.05). Conclusions: Pulmonary function disorders are significantly common in IBD patients. The impairment in active disease is significantly greater than in remission.

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Introduction: Pulmonary embolism (PE) is a serious cardiovascular and pulmonary complication worldwide. We aimed to assess the implications of different computed tomography pulmonary angiography (CTPA) parameters in patients with acute PE. Methods: A retrospective observational study to include patients presented with clinical suspicious of PE who underwent CTPA was conducted. Patients' demographics, clinical presentation, risk factors, laboratory investigations, management, and outcome were analyzed. Computed tomography findings included clot burden (Qanadli score [QS]) and right ventricular dysfunction (RVD) parameters. Results: A total of 45 patients with radiologically confirmed diagnosis of PE were included in the study; of these patients, 8 (17.8%) died during the hospital course. Patients who died were 13 years older than those who survived, and the mortality rate was significantly higher in patients with cancer. The two groups were comparable for cardiovascular parameters. The mean clot burden (QS) was 19.5 ± 11.3 points and 53% of patients had QS >18 points. Obesity (52.4% vs. 12.5%; P = 0.01), hypertension (54.4% vs. 23.8%; P= 0.03), and median D-dimer levels (7.8 vs. 3.4; P = 0.03) were significantly higher in patients with QS >18. Among right ventricular (RV) dysfunction parameters, only higher RV/left ventricular (LV) ratio (P = 0.001) and bowing of interventricular septum (P = 0.001) were associated with higher QS. A significant positive correlation was found between RV short axis (r = 0.499, P = 0.001), RV/LV ratio (r = 0.592, P = 0.001), and pulmonary artery (PA) diameter (r = 0.301, P = 0.04) with the PA clot burden. Receiver operating characteristic curve for clot burden showed a cutoff value of 17.5 points to accurately predict RV dysfunction. Conclusions: Clot burden >18 is associated with RV dysfunction in patients with acute PE. Echocardiography and RVD parameters showed no correlation with in-hospital deaths. CTPA has clinicoradiological implications for risk stratification in PE patients. As the sample size is small, our findings warrant further larger prospective studies.

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The respiratory care (RC) profession in Saudi Arabia is over 40-year-old. Although there have been major advancements in the profession, no history and enough information are available about its development and evolvement at current. This paper describes the history and development of the field of RC and future prospects for the profession in Saudi Arabia. A comprehensive review and assessment were conducted through direct contact, interviews, and a review of existing documents in the Medical Services Division of the Ministry of Defense, the Ministry of Health, The Ministry of Civil Services, representative hospitals, academic institutions, and other relevant texts. The data obtained were evaluated for its relevance and grouped on a thematic basis. This is currently the first paper about the history and development of the RC profession in Saudi Arabia over the last 45 years.

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While tuberculous vertebral osteomyelitis is an ancient scourge, multi-drug resistant-tuberculosis (MDR-TB) is a modern major public health concern. The objective of this study was to review and summarize the data available on MDR-TB spondylitis. An extensive search of the PubMed database was conducted for articles in English relevant to MDR-TB spondylitis by December 2015. Tuberculous spondylitis accounts for 0.5–1% of all TB cases, and it is estimated that there are probably 5000 MDR-TB spondylitis cases each year worldwide. The diagnosis of MDR-TB spondylitis requires a high index of suspicion based on epidemiologic, clinical, and radiologic features. Cultures and susceptibility testing remain the gold standard for the diagnosis of MDR-TB, but this can take several weeks to obtain. Medical treatment is the mainstay of therapy, and ideally, it should be based on drug susceptibility testing. If empiric treatment is necessary, it should be based on drug exposure history, contact history, epidemiology, and local drug resistance data, if available. The total duration of treatment should not be <18–24 months. Clinical, radiographic, and if possible, bacteriologic improvement should be used to assess the treatment success. Surgery should be reserved for neurologic deterioration, significant kyphosis, spinal instability, severe pain, and failure of medical management.

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Context: Respiratory physiotherapy plays a key role in the management and treatment of patients with respiratory diseases worldwide, yet this specialty is not well established in Saudi Arabia. Aims: To profile the attitudes among physicians and nurses toward physiotherapists working in respiratory care settings in Saudi Arabia. Methods: A cross-sectional questionnaire-based study was conducted. A questionnaire was developed consisting of 23 items, which was distributed both electronically and in paper form to physicians and nurses working in hospitals and health-care centers in Saudi Arabia. Physicians and nurses working outside of Saudi Arabia, and other health professionals, were excluded from the study. Results: A total of 284 questionnaires were returned (nurses: n = 158; physicians: n = 126). The majority believed that physiotherapists have the skills to be involved in respiratory care (79.9%, n = 226) and that physiotherapists are an important member of the Intensive Care Unit team (90.4%, n = 255). Most respondents (n = 232, 82.9%) felt in need of more information regarding the role of physiotherapy within respiratory care; significantly more nurses than physicians believed they needed additional education (P = 0.002). Specialized physicians were more likely than nonspecialized physicians to refer respiratory patients to physiotherapy (P < 0.05). Conclusion: Physiotherapy in respiratory care settings was positively regarded by nurses and physicians working in hospitals and health-care facilities in Saudi Arabia. The need for further education for physicians and nurses on the role of physiotherapy in respiratory care was highlighted; this would enable physiotherapy to develop and be further integrated into the respiratory care multidisciplinary team.

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Background: Pulmonary embolism (PE) is a common and potentially life-threatening disorder. Patients with PE often have nonspecific symptoms, and the diagnosis is often delayed. Aim: The aim of our study was to investigate the role of signal peptide-complement C1r/C1s, Uegf, and Bmp1-epidermal growth factor domain-containing protein 1 (SCUBE1) used in the diagnosis of PE. Methods: The study was designed prospectively. A total of 57 patients who were admitted to emergency service with clinically suspected PE were included in the study. The patients diagnosed with PE were defined as PE group (n = 32), and the patients with undetectable embolism on computerized tomographic pulmonary angiography were defined as non-PE group (n = 25). Twenty-five age- and sex-matched healthy cases were chosen for the study. Routine biochemical analysis, complete blood count, D-dimer, SCUBE1, and arterial blood gas analysis were performed early after admission. Results: Mean SCUBE1 levels were higher in the PE group (0.90 ng/mL) than in the non-PE (0.38 ng/mL) and control groups (0.47 ng/mL) (P < 0.01). A cutoff point of 0.49 ng/mL for SCUBE1 indicated 100% sensitivity and 64% specificity in patients with PE. Mean D-dimer levels were not different between PE and non-PE groups (P = 0.591). A multivariable logistic regression analysis (with dichotomous PE groups as the response variable; age, gender, chest pain, syncope, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, D-dimer, neutrophil-lymphocytes ratio, and SCUBE1 variables as predictors) showed that the significant and independent predictors of PE diagnosis were SCUBE1 and chest pain. Conclusion: This study suggests that serum SCUBE1 measurement might be used as a diagnostic biomarker in PE.

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Background: The assessment of the severity of chronic obstructive pulmonary disease (COPD) should involve a multidimensional approach that is now clearly shown to be better than using spirometric impairment alone. The aim of this study is to validate and compare novel tools without an exercise test and to extend prognostic value to patients with less severe impairment of Forced expiratory volume 1 s. Methods: A prospective, observational, primary care cohort study identified 458 eligible patients recruited from the primary care clinics in the northeast of England in 1999–2002. A new prognostic indicator - body mass index, airflow obstruction and dyspnea (BOD) together with the conventional prognostic indices age, dyspnea and airflow obstruction (ADO), global initiative for chronic obstructive lung disease (GOLD) and new GOLD matrix were studied. We also sought to improve prognostication of BOD by adding age (A) and smoking history as pack years (S) to validate BODS (BOD with smoking history) and BODAS (BOD with smoking history and age) as prognostic tools and the predictive power of each was analyzed. Results: The survival of the 458 patients was assessed after a median of 10 years when the mortality was found to be 33.6%. The novel indices BOD, BODS, and BODAS were significantly predictive for all-cause mortality in our cohort. Furthermore with ROC analysis the C statistics for BOD, BODS, and BODAS were 0.62, 0.66, and 0.72, respectively (P < 0.001 for each), whereas ADO and GOLD stages had a C statistic of 0.70 (P < 0.001) and 0.56 (P < 0.02), respectively. GOLD Matrix was not significant in this cohort. Conclusion: BOD, BODS, and BODAS scores are validated predictors of all-cause mortality in a primary care cohort with COPD.

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There are several described pulmonary complications due to laparoscopic adjustable gastric banding. We report a rare case of a 32-year-old male who presented with pulmonary symptoms and a solitary lung mass 12 years after laparoscopic adjustable gastric banding. A bronchoscopic lung biopsy showed organizing pneumonia that was induced by aspiration pneumonia. The atypical radiological appearance of the aspiration pneumonia may pose a diagnostic challenge, and clinicians' awareness regarding such an entity is needed to avoid unnecessary intervention.

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