Annals of Thoracic Medicine Official publication of the Saudi Thoracic Society, affiliated to King Saud University
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   2021| July-September  | Volume 16 | Issue 3  
    Online since July 20, 2021

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Clinical profiles associated with SARS-CoV-2 infection and complications from coronavirus disease-2019 in children from a national registry in Saudi Arabia
Yasir Almuzaini, Fahad Alsohime, Sarah Al Subaie, Mohamad Hani Temsah, Yousef Alsofayan, Fahad Alamri, Ahmed Alahmari, Hadil Alahdal, Hana Sonbol, Rana Almaghrabi, Mahmoud Nahhas, Anas Khan
July-September 2021, 16(3):280-286
CONTEXT: Exploring clinical characteristics of coronavirus disease-19 (COVID-19) in children may help in prevention and treatment guidelines. AIMS: The aim of the to describe the spectrum of pediatric COVID-19 in Saudi Arabia. SETTINGS And DESIGN: A multicenter, retrospective, cross-sectional study involving pediatric COVID-19 patients across all Saudi regions. METHODS: All patients aged between 2 months and 18 years with a confirmed diagnosis of COVID-19 were included. The primary end point was the hospitalization. STATISTICAL ANALYSIS USED: Descriptive statistics were used to describe the baseline demographic data and clinical characteristics. Numerical data were explored using Kolmogorov–Smirnov test and Shapiro–Wilk test, while Chi-square or Fisher's exact test were used for categorical data. RESULTS: Among the 654 pediatric COVID-19 patients, 4.7% (n = 31) were hospitalized, with one patient only needing pediatric intensive care admission. Sex, breastfeeding, birth status, and the patients' living environment showed no significant association with hospitalization. Most children (80.3%, n = 525) were symptomatic, with two symptoms that were significantly associated with admission, namely, vomiting (P = 0.007) and nausea (P = 0.026). History of admission within the last year was identified in 10.4% (n = 68) children but had no association with worse outcome. The median duration of hospitalization for the entire group was 5.5 days, with longest hospital stay for age group 7–12 years (median 6 days). CONCLUSIONS: COVID-19 is usually a milder disease in children. Although having preexisting medical conditions was linked to a longer hospitalization, it was not associated with worse outcome. Continuous surveillance will allow additional characterization of the burden and outcomes of pediatric COVID-19-associated hospitalizations.
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Post-COVID-19 functional status: Relation to age, smoking, hospitalization, and previous comorbidities
Aliae A R Mohamed Hussein, Mahmoud Saad, Hossam Eldeen Zayan, Mustafa Abdelsayed, Mohamed Moustafa, Abdel Rahman Ezzat, Radwa Helmy, Howaida Abd-Elaal, Karim Aly, Shaimaa Abdelrheem, Islam Sayed
July-September 2021, 16(3):260-265
RATIONAL: Recently, a new “Post-COVID-19 Functional Status (PCFS) scale” is recommended in the current COVID-19 pandemic. It is proposed that it could be used to display direct retrieval and the functional sequelae of COVID-19. AIM OF THE STUDY: The aim of the study was to assess the PCFS and to evaluate if age, gender, smoking, hospitalization, and comorbidities have any effect on functional limitations in recovered COVID-19 patients. METHODS: A total of 444 registered confirmed COVID-19 patients were included. They were interviewed in our follow-up clinics and filled an Arabic translated PCFS scale as well as their demographic and clinical data. RESULTS: Eighty percent of COVID-19 recovered cases have diverse degrees of functional restrictions ranging from negligible (63.1%), slight (14.4%), moderate (2%), to severe (0.5%) based on PCFS. Furthermore, there was a substantial variance between the score of PCFS with age (P = 0.003), gender (P = 0.014), the duration since the onset of the symptoms of COVID-19 (P < 0.001), need for oxygen supplementation (P < 0.001), need for intensive care unit (ICU) admittance (P = 0.003), previous periodic influenza vaccination (P < 0.001), smoking status (P < 0.001), and finally, the presence of any comorbid disorder (P < 0.001). CONCLUSIONS: Most of the COVID-19 recovered cases have diverse degrees of functional restrictions ranging from negligible to severe based on PCFS. These restrictions were affected by age, gender, periodic influenza vaccination, smoking, duration since symptoms onset, need for oxygen or ICU admittance, and finally the presence of coexisting comorbidity.
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Point-of-care diagnostic lung ultrasound is highly applicable to the practice of medicine in Saudi Arabia but the current skills gap limits its use
Rajkumar Rajendram, Mamdouh Souleymane, Naveed Mahmood, Mubashar Kharal, Mohammad AlQahtani
July-September 2021, 16(3):266-273
CONTEXT: Coronavirus disease 2019 (COVID-19) has put a spotlight on point-of-care diagnostic lung ultrasound (POCDLUS). However, the spectra of respiratory disease and resources available for investigation vary internationally. The applicability of POCDLUS to internal medicine (IM) practice in Saudi Arabia and the current use by Saudi physicians are unknown. AIMS: The aim of the present study was to determine the applicability of POCDLUS to IM practice in Saudi Arabia and quantify the residents' current skills, accreditation, and use of POCDLUS. METHODS: A questionnaire was distributed to the IM residents at our institution to assess their knowledge, use of POCDLUS, and their perceptions of its applicability in IM. STATISTICAL ANALYSIS: Standard descriptive statistical techniques were used. Categorical data, presented as frequency, were compared using the Chi-squared test. The Likert scale responses, presented as mean ± standard deviation, were compared with a Student's t-test. RESULTS: In total, 100 residents participated (response rate 92.6%) and reported that POCDLUS was applicable to their practice. Identifying pleural effusions was most applicable. A small proportion (n = 7) had received training, nine used POCDLUS regularly, none were accredited and the overall self-reported level of knowledge was poor. CONCLUSIONS: Whilst POCDLUS is applicable to IM practice in Saudi Arabia, the significant skills gap preclude the provision of a POCDLUS service. As COVID-19 can cause an interstitial syndrome, our pandemic preparation response should include POCDLUS training. The current study is supported by a similar Canadian study and the international standardisation of POCDLUS training may be feasible. The findings of the current study may facilitate the development of POCDLUS training programs for internists throughout Saudi Arabia.
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Molecular detection of plasmid-derived AmpC β-lactamase among clinical strains of Enterobacteriaceae in Bahrain
Ronni Mol Joji, Ali Ebrahim Al-Mahameed, Thamer Al Jishi, Dania Ismail Fatani, Nermin K Saeed, Ahmed Jaradat, Hicham Ezzat, Khalid Mubarak Bindayna
July-September 2021, 16(3):287-293
BACKGROUND: Enterobacteriaceae with AmpC β-lactamase are multidrug-resistant organisms and represent a significant challenge to patient care. This study aims to determine the prevalence of plasmid-derived AmpC β-lactamase among extended spectrum β-lactamases (ESBL)-producing Enterobacteriaceae strains in Bahrain. METHODS: It was a cross-sectional study. A total of 185 ESBL-producing Enterobacteriaceae isolates were recovered from clinically significant specimens from January 2018 to December 2019. The samples underwent initial screen for cefoxitin resistance by disc diffusion test and subsequent phenotypic confirmation of AmpC production with phenyl boronic acid assays as well as genotypic analysis by multiplex polymerase chain reactions for AmpC subtypes. Drug-resistant features of these clinical isolates were also examined. RESULTS: Twenty-nine ESBL-producing Enterobacteriaceae isolates were cefoxitin resistant. Phenotypic and genotypic analyses confirmed that 8 and 12 cefoxitin-resistant isolates are AmpC positive, respectively. These AmpC producers are multidrug resistant, and Escherichia coli is the dominant strain among them. CONCLUSIONS: Plasmid-mediated spread of AmpC is present in clinically relevant Enterobacteriaceae species in Bahrain. Rational antimicrobial therapy against these multidrug-resistant organisms and continued surveillance of antimicrobial resistance mechanisms among the clinical isolates are recommended for optimal patient care.
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Fatal rapidly progressive interstitial lung disease in a patient with amyopathic dermatomyositis
Abdullah Mobeireek, Walter Conca, Shamayel Mohammed, Fahad AlObaid, Mohammed AlHajji
July-September 2021, 16(3):294-298
Interstitial lung disease (ILD) is a well-established common manifestation of idiopathic inflammatory myopathies. Yet, till now, the pathogenetic mechanisms are still poorly understood, classification is evolving and prognosis is variable. A refractory and rapidly progressive ILD (RPILD) that is associated with dermatomyositis (DM) with minimal muscle weakness and normal creatine kinase (termed clinically amyopathic DM) is increasingly being recognized, with more incidence in Asians. However, we are not aware of reports of the Arab region. Herein, we present a 38-year-old male with this condition that ended with a fatal outcome despite aggressive therapy, with a review of recent literature.
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Gone with the wind! Changes in the practice of bronchoscopy post pandemic: A perspective
Himanshu Deshwal, Atul C Mehta, Mohammed Munavvar
July-September 2021, 16(3):221-224
  - 1,330 195
Joint consensus statement of the Saudi Public Health Authority on the recommended amount of physical activity, sedentary behavior, and sleep duration for healthy Saudis: Background, methodology, and discussion
Ahmed S BaHammam, Abdullah F Alghannam, Khalid Saad Aljaloud, Ghadeer S Aljuraiban, Mezna A AlMarzooqi, Ali M Dobia, Shaima A Alothman, Osama Aljuhani, Rasha A Alfawaz
July-September 2021, 16(3):225-238
The Saudi Public Health Authority recently prepared a Consensus Statement regarding how much time a person should spend engaged in physical activity, sedentary behavior, and sleep to promote optimal health across all age groups. This paper describes the background literature, methodology, and modified RAND Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-ADOLOPMENT approach that guided the development process. A Leadership Group and Consensus Panels were formed, and credible existing guidelines were identified. The Panel identified clear criteria to choose the best practice guidelines for the set objectives after evaluation, based on GRADE table evidence, findings table summaries, and draft recommendations. Updating of the selected practice guidelines was performed, and the Consensus Panels separately reviewed the evidence for each behavior and decided to adopt or adapt the selected practice guideline recommendations or create de novo recommendations. Data related to cultural factors that may affect the studied behaviors, such as prayer times, midday napping or “Qailulah,” and the holy month of Ramadan, were also reviewed. Two rounds of voting were conducted to reach a consensus for each behavior.
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The recommended amount of physical activity, sedentary behavior, and sleep duration for healthy Saudis: A joint consensus statement of the Saudi Public Health Authority
Rasha A Alfawaz, Ghadeer S Aljuraiban, Mezna A AlMarzooqi, Abdullah F Alghannam, Ahmed S BaHammam, Ali M Dobia, Shaima A Alothman, Osama Aljuhani, Khalid Saad Aljaloud
July-September 2021, 16(3):239-244
BACKGROUND: The goal of the 24-h Movement Practice Guidelines for Saudi Arabia is to provide policymakers, health-care providers, researchers, sports professionals, and members of the public with recommendations on the duration of time they should spend engaged in physical activity, sedentary behavior, and sleep throughout all age groups. METHODS: A modified RAND appropriateness method and the “GRADE-ADOLOPMENT” approach of guideline recommendations were used by a guideline development panel to develop the present recommendations. RESULTS: The recommendations were based on the integrated needs of the following age groups: children (0–2 years), preschoolers (3–5 years), children and adolescents (6–17 years), adults (18–64 years), and older adults (≥65 years). The guidelines also include special considerations for sleep duration in the Saudi culture, such as dawn prayer and Ramadan. CONCLUSIONS: Several research gaps in physical activity, sedentary behavior, and sleep were identified and highlighted by the guideline development panel for potential future research.
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The efficacy of airway pressure release ventilation in acute respiratory distress syndrome adult patients: A meta-analysis of clinical trials
Fatmah Othman, Noura Alsagami, Reem Alharbi, Yara Almuammer, Shatha Alshahrani, Taha Ismaeil
July-September 2021, 16(3):245-252
BACKGROUND: To recruit poorly ventilated lung areas by providing active and adequate oxygenation is a core aspect of treating patients with acute respiratory distress syndrome (ARDS). The airway pressure release ventilation (APRV) mode is increasingly accepted as a means of supporting patients with ARDS. This study aimed to determine whether the APRV mode is effective in improving oxygenation, compared to conventional ventilation, in adult ARDS patients. METHODS: We conducted the study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched for clinical trials in PubMed, Embase, Web of Science, and the Cochrane Library until April 2019. We included all studies comparing APRV and other conventional mechanical ventilation modes for adult ARDS patients. Our primary outcome was oxygenation status (defined as the day 3 PaO2/FiO2 ratio). The secondary outcomes were the length of stay (LOS) in the intensive care unit (ICU) and mortality. Sensitivity analyses were performed including studies with conventional low-tidal volume ventilation as a comparator ventilation strategy. RESULTS: We included six clinical trials enrolling a total of 375 patients. The day 3 PaO2/FiO2 was reported in all the studies, and it was significantly higher in patients receiving APRV (mean difference [MD] 51.9 mmHg, 95% confidence intervals (CI) 8.2–95.5, P = 0.02, I2 = 92%). There was no significant difference in mortality between APRV and the other conventional ventilator modes (risk difference 0.07, 95% CI: −0.01–0.15, P = 0.08, I2 0%). The point estimate for the effect of APRV on the LOS in ICU indicated a significant reduction in the ICU LOS for the APRV group compared to the counter group (MD 3.1 days, 95% CI 0.4–5.9, P = 0.02, I2 = 53%). CONCLUSION: In this study, using the APRV mode may improve oxygenation on day 3 and contribute to reducing the LOS in ICU. However, it is difficult to draw a clinical message about APRV, and well-designed clinical trials are required to investigate this issue.
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Small-airway disease and its reversibility in human immunodeficiency virus-infected children on highly active antiretroviral therapy: A cross-sectional study in an African setting
Adaeze C Ayuk, Chizalu I Ndukwu, Samuel N Uwaezuoke
July-September 2021, 16(3):253-259
BACKGROUND: Lung function abnormalities may occur in children with human immunodeficiency virus (HIV) infection. Small-airway disease (SAD) precedes abnormalities in forced expiratory volume in 1 s (FEV1). OBJECTIVE: This study aims to assess the presence and reversibility of SAD in HIV-infected children using the Global Lung Function Initiative standards. METHODS: A cross-sectional study was conducted over 6 months at the Paediatric HIV Clinic of the University of Nigeria Teaching Hospital in Enugu, Southeast Nigeria. Eligible consenting children with HIV infection were recruited. Lung function was measured, and the reversibility of FEV1 and forced vital capacity (FVC) was assessed at 12% while that of forced expiratory flow between 25% and 75% (FEF25-75) was assessed at 12%, 15%, and 20%. Predictors of abnormal Z-score values were determined by multivariate linear and logistic regressions. Statistically significant values were set at P < 0.05. RESULTS: The mean Z-score for FEV1, FVC, and FEF25-75 was − 2.19, −1.86, and − 1.60, respectively. Most patients (73%) had abnormal FEV1, while 52% had abnormal FEF25-75. Significant changes in FEV1 (P = 0.001) and FEF25-75 (P < 0.001) occurred after the bronchodilator response (BDR) test. Of the children whose FEV1 showed positive BDR, 70.9% had low zFEV1; 50% had low zFEF25-75, while all had low FEV1. Nutritional status (Z-score for body mass index) was significantly associated with low FEV1. CONCLUSIONS: Abnormal FEF25-75 as a marker of SAD and FEV1 with a positive BDR are common in HIV-infected children. These lung function abnormalities justify long-term follow-up for these patients.
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Pulmonary neuroendocrine carcinoid tumors: Is there a predictive role to the Ki 67 index?
Ana Karina Patane, Gabriela Guma, Mercedes Rayá, Adolfo Rosales, Walter Astorino, Moisés Rosenberg
July-September 2021, 16(3):274-279
INTRODUCTION: There are several factors predicting evolution in carcinoid tumors (CT) to date including the Ki67 role. AIMS: The aim of this study is to identify a KI67 cut-off point for a population of CT and determine its prognostic implication in global and disease-free survival. METHODS: Hematoxylin-eosin slides of 102 CT were revised. The percentage of cells expressing Ki 67 was determined manually. STATISTICAL ANALYSIS: The variables were compared with the t-test or the Wilcoxon test according to their distribution, the categorical ones with Chi-square or Fisher's test. The best cut-off point was established by constructing receiver operating characteristic curves, then using that value as a dichotomous variable. RESULTS: 72 typical carcinoids (TC) and 30 atypical carcinoids (AC) were analyzed; 66% were female. Median age (TC 38 vs. AC 51, P = 0.001), Ki67 expression (TC 0.63 vs. AC 2, P = 0.003), tumor size (TC 2.5 vs. AC 2.6, P = 0.001), the percentage relapse (TC 3.4% vs. AC 23%, P = 0.006), and the number of deaths (TC 1 vs. AC 4, P = 0.042) were significantly higher in the AC subgroup. The best cut-off point for Ki 67 was 0.755 (area under the curve AUC 0.564, 95% confidence interval 0.270–0.857), with no significant differences found in the disease-free and overall survival curves when considering values < or ≥ at the established cut-off point. The best cut-off point of the Ki-67 when exclusively analyzing AC was 1.18. When using this value as a predictive variable, a marginal statistical association was observed between Ki-67 expression, mortality (P = 0.077), and the frequency of relapses (P = 0.054). CONCLUSIONS: Histological type is the best predictor of prognosis in the carcinoid tumor group. In the AC subgroup, the marginal association between mortality, frequency of relapses and Ki values 67 ≥ 1.18 has clinical relevance future analyses are required to determine the real predictive value of this variable.
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