BackgroundThe purpose of this study was to analyze the perceptions and practices of internal medicine residents in the western region of Saudi Arabia regarding the implementation of do not resuscitate (DNR) orders to improve future training practices among physicians.MethodsMedical residents involved in training programs in the western region of Saudi Arabia, including Jeddah, Makah, Medinah, and Taif, were invited to participate in a cross-sectional, anonymous, online survey regarding DNR orders. The 16-question survey was distributed to residents in all training programs in the region using surveymonkey.com, and the results were collected and tabulated.ResultsOf 364 residents, 157 completed the questionnaire, resulting in a 43% response rate. The study showed that most (66%) internal medicine residents in the western region of Saudi Arabia participate in DNR discussions with patients and family or surrogate decision-makers. In addition, 43% were observed by faculty members, and half of them (51.9%) reported feeling comfortable during these discussions. Furthermore, most residents believed that additional educational programs would enhance their competence in addressing issues related to DNR discussions.ConclusionThis study highlights the need for a structured curriculum to teach skills relating to end-of-life issues such as DNR orders to residents in the Saudi Arabian medical system. The majority of residents surveyed believe they would benefit from additional training in DNR discussions. Therefore, an evidence-based curriculum providing instruction for improving discussions regarding DNR orders would improve physician confidence and effectiveness in caring for critically ill patients.

Purpose: To determine the prevalence of common sleep problems among patients with rheumatoid arthritis (RA) and their relationship with the disease activity and quality of life. Patients and methods: The study sample consisted of 101 patients who attended a rheumatology clinic at a university hospital between October 2015 and May 2016. All subjects were clinically examined and interviewed by physicians using a questionnaire. The collected information included sociodemographic characteristics, the patients’ medical histories, the Disease Activity Score (DAS28), the Berlin questionnaire to assess the risk of obstructive sleep apnea (OSA), the Epworth Sleepiness Scale to assess excessive daytime sleepiness (EDS), the Athens Insomnia Scale to assess insomnia, the International RLS Study Group score to diagnose restless legs syndrome (RLS), and the Health Assessment Questionnaire (HAQ) to assess the quality of life. Results: The mean age of the participants was 48.7±14.6 years, and 95% of the participants were females. Approximately 60% of the participants were in the remission/low category of disease activity, and the average DAS28 score was 3.3±0.8 years. The prevalence rates of insomnia, EDS, sleep disturbance, risk of OSA, and RLS were 63%, 20%, 20%, 37%, and 63%, respectively. Furthermore, the distribution of sleep disorders was not affected by the disease activity. The association between the HAQ and sleep disorders among the RA patients was not significant. Conclusion: Sleep disorders are common among RA patients and may require further attention by treating clinicians; nevertheless, these disorders are not associated with disease activity and do not affect the quality of life.

Objectives:To determine the mortality rates and predictors among patients hospitalized with active tuberculosis (TB) at King Abdulaziz University Hospital (KAUH) in Jeddah.Methods:A retrospective study was performed on 291 active TB patients hospitalized in KAUH, Jeddah, Saudi Arabia from December 2011 to December 2016. Medical records were collected and evaluated using a dedicated data extraction sheet. The records included demographics, clinical, radiological, laboratory, and drug resistance data.Results:Of the 291 patients, 168 had pulmonary TB, 39 had extrapulmonary TB, and 84 had both pulmonary and extrapulmonary TB. After a mean hospital stay of 1.74 months, 85.9% were successfully treated and discharged. However, 14% died in the hospital after a mean stay of 1.87 months. Predictors of inpatient TB mortality were older age, congestive heart failure, renal failure, diabetes mellitus, chronic lung disease, hepatitis B virus infection, bilateral pulmonary TB, miliary TB, pleural effusion, and leukopenia. In particular, a logistic regression model revealed a mortality probability of 90% in patients older than 65 with congestive heart failure and bilateral lung involvement. However, drug resistance did not significantly affect the mortality rate.Conclusions:The inpatient TB mortality rate was lower than mortality rates described previously. Nevertheless, early recognition, appropriate treatments, and education for patients and caregivers concerning treatment, efficient medical management, and effective preventive measures can further reduce mortality.

AIMS: Flexible bronchoscopy is a common procedure performed in pulmonary medicine, critical care, and thoracic surgery. In this study, we aimed to assess the prevalence and predictors of anxiety in patients undergoing diagnostic bronchoscopy. METHODS: This is a prospective study conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia. All patients undergoing diagnostic bronchoscopy filled the State-Trait Anxiety Inventory questionnaire before the procedure. Bronchoscopy was performed either through the mouth or the nose, based on the bronchoscopist preference. Lidocaine (1%–2%) spray was used for administering topical anesthesia. Results were collected, and statistical analysis was performed using t -test to measure statistically significant ( P < 0.05). RESULTS: A total of 117 patients participated in this study. High anxiety score was found in 45% of the patients. Older patients significantly showed higher anxiety score than younger patients (53 years vs. 46 years, P = 0.034). Similarly, patients with higher body mass index (BMI) showed a statistically significant increase in anxiety score (28 vs. 25, P = 0.041). Premedication with pethidine significantly reduced the anxiety levels (26.9% vs. 73.1%, P = 0.031). Logistic regression demonstrated that old age and outpatient settings were significant predictors of higher anxiety scores. CONCLUSION: Diagnostic bronchoscopy can cause high anxiety in many patients. Prebronchoscopy anxiety assessment can help bronchoscopists to anticipate the anxiety levels of patients, and then further use it to tailor sedation requirements. Special attention should be given to older patients, patients with high BMI, and the ones undergoing bronchoscopy in outpatient settings.

Background. High HIV burden countries have experienced a high burden of pleural TB in HIV-infected patients. Objective. To review the epidemiology, immunopathogenesis, diagnosis, and treatment of pleural TB in HIV-infected patients. Methods. A literature search from 1950 to June 2011 in MEDLINE was conducted. Results. Two-hundred and ninety-nine studies were identified, of which 30 met the inclusion criteria. The immunopathogenesis as denoted by cells and cytokine profiles is distinctly different between HIV and HIV-uninfected pleural TB disease. Adenosine deaminase and interferon gamma are good markers of pleural TB disease even in HIV-infected patients. HIV-uninfected TB suspects with pleural effusions commonly have a low yield of TB organisms however the evidence suggests that in dually infected patients smear and cultures have a higher yield. The Gene Xpert MTB/RIF assay has significant potential to improve the diagnosis of pleural TB in HIV-positive patients. Conclusions. Pleural TB in HIV-infected patients has a different immunopathogenesis than HIV-uninfected pleural TB and these findings in part support the differences noted in this systematic review. Research should focus on developing an interferon gamma-based point of care diagnostic test and expansion of the role of Gene Xpert in the diagnosis of pleural TB.

AIMS:The aim of the study was to evaluate the clinical utility and safety of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with mediastinal and hilar lymphadenopathy and to explicitly describe the utility of this procedure in patient's outcome.METHODS:A retrospective review and analysis was conducted on 52 patients with mediastinal or hilar lymphadenopathy who underwent EBUS-TBNA from June 2012 to June 2016. All the patients were evaluated by computed tomography (CT) chest with contrast before EBUS examination. Enlarged mediastinal or hilar lymph node was defined as >1 cm short axis on the enhanced CT.RESULTS:Among the 52 patients studied, 57.7% were presented with mediastinal or hilar lymphadenopathy for diagnosis and 42.3% presented with suspected mediastinal malignancy. Paratracheal stations were the most common site for puncture in 33 lymph nodes (43%). The best diagnostic yield was obtained from subcarinal stations and the lowest yield from the hilar stations. Surgical biopsies confirmed lymphoma in six patients, tuberculosis (TB) in three, sarcoidosis in two and one had metastatic adenocarcinoma of unknown primary. The sensitivity, specificity, positive predictive value, and negative predictive value of EBUS-TBNA for diagnosis of mediastinal and hilar lymph node abnormalities were 78.6%, 100%, 100%, and 80%, respectively. The diagnostic yield of EBUS-TBNA in malignant and benign conditions was 79.0%.CONCLUSIONS:EBUS-TBNA is a safe and efficacious procedure which can be performed using conscious sedation with high yields. It can be used for the staging of malignancies as well as for the diagnosis of inflammatory and infectious conditions such as sarcoidosis and TB.

Chylothorax is characterized by the accumulation of chyle in the pleural space, of which the most common cause is trauma or neoplasm. Although chylothorax accounts for a small proportion of clinical pleural effusions, prompt recognition is needed to avoid malnutrition, immunodeficiency, and fibrothorax. We report 2 patients with superior vena cava obstruction caused by tunneled venous catheters resulting in chylothorax and demonstrate the potential safety of tunneled pleural catheters for prolonged chylothorax drainage in an outpatient setting with rigorous follow-up. Changes in pleural fluid chemistries of the effusions and the possible pathophysiology were assessed with a review of the literature on pleural fluid chemistries in superior vena cava obstruction.

Re-infection with different SARS-CoV-2 clade and prolonged viral shedding in a patient with hematopoietic stem cell transplantation,