Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable condition, in which outcomes can be improved with careful management. Pulmonary rehabilitation (PR) comprises exercise and education, delivered by multidisciplinary teams. PR is a cost-effective management strategy in COPD patients which improves exercise performance, reduces dyspnea, reduces the risk of exacerbation, and improves health-related quality of life. All COPD patients appear to benefit irrespective of their baseline function, and PR has also been shown to be a clinically and cost-effective management approach following an acute exacerbation. COPD patients with greater disability and those recovering postexacerbation should be specifically targeted for PR. Due to limited current capacity, the latter group may not currently be able to benefit from PR. Therefore, there is a need for the wider implementation of PR services in Saudi Arabia, requiring us to address challenges including capacity and workforce competency.

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BACKGROUND: Previous studies have reported increased levels of inflammatory mediators in patients with obstructive sleep apnea (OSA), but their relation with the severity of OSA is controversial. OBJECTIVE: To address potential relationships between OSA-related inflammatory markers, namely, C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and fibrinogen, with different oxygenation parameters and with BMI. METHODS: All eligible patients with suspected OSA newly referred to the Sleep Medicine Research Center at King Abdulaziz University Hospital, Jeddah, were evaluated demographically and anthropometrically, and underwent overnight polysomnography. Fasting morning blood samples were collected to measure serum levels of CRP, fibrinogen, TNF-α, and IL-6. Potential correlations between these inflammatory mediators and severity measures of OSA and body mass index (BMI) were explored. RESULTS: Sixty-four patients completed the study (40 with OSA and 24 without OSA). Significantly increased levels of CRP, fibrinogen, IL-6, and TNF-α emerged in patients with OSA compared to non-OSA. Significant associations between log CRP and log fibrinogen levels emerged with increasing BMI. However, there was no significant association between any of the inflammatory markers and the severity of OSA based on the apnea/hypopnea index or oxyhemoglobin saturation-derived parameters. CONCLUSIONS: OSA patients exhibit increased levels of inflammatory mediators that do not appear to be associated with polysomnographic measures, but exhibit positive correlation with the degree of adiposity.

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BACKGROUND: The curfews and lockdowns imposed during the COVID-19 pandemic may decreased the volume of traffic and reduced air pollution. In addition, social distancing measures may contribute to reducing infection and asthma exacerbation. OBJECTIVE: The objective of this study was to assess asthma control and asthma medication use among severe asthmatics on biologics before and after the COVID-19 pandemic. METHODS: This is a cross-sectional survey study of patients with severe asthma receiving biologic therapy at King Abdulaziz Medical City-Riyadh, Saudi Arabia. We looked at the effects of the COVID-19 lockdown on this cohort of severe asthmatics on biologic therapy from March till June 2020 over a period of 12 weeks. We investigated changes in patients' symptoms and asthma control using the asthma control test (ACT) score and other parameters including emergency department visits, hospitalizations, use of oral prednisolone, changes in inhaler therapy, frequency of bronchodilator use, and patient perception of their symptoms before and after the lockdown period. RESULTS: A total of 56, Female 39 (69%), mean age ± SD 47.4 ± 13.8 years. The duration of bronchial asthma since diagnosis ranged from 4 to 30 years. Most patients had been treated with omalizumab (47, 84%); the rest received mepolizumab (7, 12.5%) and dupilumab (2, 3.6%). All these patients had been on biologic therapy for 5 months, ranging from 5 to 120 months. Most of the patients (45, 80.4%) agreed that their symptoms of asthma had improved with biologic therapy. Most of the patients felt that overall asthma symptoms are better after curfew and lockdown 28 (50%). Less use of bronchodilators postcurfew was reported in 38% of the patients. Asthma control (≥20) using ACT score was significantly higher among patients in postcurfew and lockdown period compared to precurfew period 34 (61.7%) and 23 (41%) (P = 0.001), respectively. CONCLUSIONS: Asthma control was better postcurfew and lockdown. A decrease in air pollution and social distances may be a contributing factor.

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BACKGROUND: Bronchial anthracofibrosis is a common disease that has been reported in the past. We aim to summarize the clinical characteristics of bronchial anthracofibrosis combined with tuberculosis infection to reduce missed diagnosis. METHODS: The clinical features of two cases of bronchial anthracofibrosis combined with tuberculosis were analyzed retrospectively, and relevant studies were reviewed. RESULTS: The two patients were both elderly individuals who presented with chronic cough and expectoration. Pigmentation in the bronchus mucosa and stenosis of lumen were observed during bronchoscopy. Tuberculosis infection was confirmed by biopsy. The symptoms were remarkably relieved and no recurrence was found after anti-tuberculosis treatment. CONCLUSION: Bronchial anthracofibrosis may be combined with tuberculosis. To avoid misdiagnosis, we should be aware of possible tuberculosis infection when patients are diagnosed with bronchial anthracofibrosis.

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OBJECTIVES: With the introduction of newer molecular diagnostic tools to identify Mycobacterium tuberculosis, an increasing number of nontuberculous mycobacterium (NTM) is being identified. However, the drug resistance pattern of the NTM species identified is less explored. The objective of this study is to study the drug resistance patterns of Mycobacterium kansasii species isolated in a tuberculosis-endemic setting at South India. METHODS: A wide profile of NTM species were reported earlier from a prospective cohort of adults during 2017–2020. Out of this profile, a total of 22 M. kansasii species were subjected to drug susceptibility testing by two different methods: proportion sensitivity testing method and Sensititre testing method. RESULTS: Out of the 18 strains of M. kansasii subjected to Sensititre method of testing, the resistance pattern was demonstrated to be high for doxycycline (13) followed by rifampicin and trimethoprim/sulfamethoxazole (7). Out of the 22 strains subjected to proportion sensitivity testing method, 20 and 10 were resistant to isoniazid and ethambutol, respectively. CONCLUSION: There was a poor correlation between the treatment outcome and the resistance pattern of the antibiotics tested. With increasing numbers of NTM being reported, early and correct identification of NTM species is essential for the prompt initiation of appropriate treatment to achieve better outcome.

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BACKGROUND: Acute mountain sickness (AMS) is a benign and self-limiting syndrome, but can progress to life-threatening conditions if leave untreated. This study aimed to assess the efficacy of acetazolamide for the prophylaxis of AMS, and disclose factors that affect the treatment effect of acetazolamide. METHODS: Randomized controlled trials comparing the use of acetazolamide versus placebo for the prevention of AMS were included. The incidence of AMS was our primary endpoint. Meta-regression analysis was conducted to explore factors that associated with acetazolamide efficacy. Trial sequential analyses were conducted to estimate the statistical power of the available data. RESULTS: A total of 22 trials were included. Acetazolamide at 125, 250, and 375 mg/bid significantly reduced incidence of AMS compared to placebo. TAS indicated that the current evidence was adequate confirming the efficacy of acetazolamide at 125, 250, and 375 mg/bid in lowering incidence of AMS. There was no evidence of an association between efficacy and dose of acetazolamide, timing at start of acetazolamide treatment, mode of ascent, AMS assessment score, timing of AMS assessment, baseline altitude, and endpoint altitude. CONCLUSION: Acetazolamide is effective prophylaxis for the prevention of AMS at 125, 250, and 375 mg/bid. Future investigation should focus on personal characteristics, disclosing the correlation between acetazolamide efficacy and body mass, height, degree of prior acclimatization, individual inborn susceptibility, and history of AMS.

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BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is uncommon but well-known sequel of venous thromboembolism (VTE). At present, it is the only potential curable subtype of pulmonary hypertension. The aim of this study is to describe the medically treated-CTEPH patients' characteristics in a single specialized PH center in Saudi Arabia. METHODS: This study presents demographic, clinical, physiological, and hemodynamic characteristics of medically treated-CTEPH patients in a single PH center, namely Prince Sultan Military Medical City, Riyadh, Saudi Arabia. Both incident and prevalent cases are included. RESULTS: A total of 20 patients with a confirmed diagnosis of CTEPH were included. Mean age at diagnosis was 43 years with a female preponderance of 75%. Most common presenting symptom was dyspnea (100%) followed by syncope (58%). At diagnosis, a mean of 15 ± 10 months had passed since symptoms onset. About 45% of patients were in WHO functional class IV. At baseline, mean 6-min walk distance was 354.3 meters. Overall, VTE was the most frequent risk factor identified (65% of all patients). Nearly 30% of patients had sickle cell disease. 13 out of 20 patients had radiographic (i.e., computed tomography [CT] pulmonary angiogram) features of chronic thromboembolism. About 75% of patients were found to have distal disease on radiographic imaging. At the time of diagnosis, 7 out of 20 (35%) patients demonstrated right ventricular failure on echocardiography. Mean tricuspid annular plane systolic excursion was 17.7 ± 1.20. Median NT-proBNP levels were found to be 688 pg/ml. Mean diffusing capacity for carbon monoxide was 74.8%. CONCLUSIONS: Diagnosis of CTEPH was established at a relatively younger age. Majority of patients had advanced but distal disease on radiographic imaging, not amenable to surgery.

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The effectiveness of bi-level positive airway pressure (BiPAP) in patients with acute hypercapnic respiratory failure (AHRF) due to etiologies other than chronic obstructive pulmonary disease (COPD) is unclear. To systematically review the evidence regarding the effectiveness of BiPAP in non-COPD patients with AHRF. The Cochrane Library, MEDLINE, EMBASE, and CINAHL Plus were searched according to prespecified criteria (PROSPERO-CRD42018089875). Randomized controlled trials (RCTs) assessing the effectiveness of BiPAP versus continuous positive airway pressure (CPAP), invasive mechanical ventilation, or O₂ therapy in adults with non-COPD AHRF were included. The primary outcomes of interest were the rate of endotracheal intubation (ETI) and mortality. Risk-of-bias assessment was performed, and data were synthesized and meta-analyzed where appropriate. Two thousand four hundred and eighty-five records were identified after removing duplicates. Eighty-eight articles were identified for full-text assessment, of which 82 articles were excluded. Six studies, of generally low or uncertain risk-of-bias, were included involving 320 participants with acute cardiogenic pulmonary edema (ACPO) and solid tumors. No significant differences were seen between BiPAP ventilation and CPAP with regard to the rate of progression to ETI (risk ratio [RR] = 1.49, 95% confidence interval [CI], 0.63–3.62, P = 0.37) and in-hospital mortality rate (RR = 0.71, 95% CI, 0.25–1.99, P = 0.51) in patients with AHRF due to ACPO. The efficacy of BiPAP appears similar to CPAP in reducing the rates of ETI and mortality in patients with AHRF due to ACPO. Further research on other non-COPD conditions which commonly cause AHRF such as obesity hypoventilation syndrome is needed.

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