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Objective: To determine the relationship between the asthma control test (ACT) score using the Arabic version, fractional exhaled nitric oxide (FENO), and lung functions, and to derive the cutoff points for the ACT score with the American Thoracic Society recommended FENO standard levels of inflammation control., Methods: We recruited 59 adult asthmatics out of which 53 subjects completed the study between July 2011 and June 2012 at King Saud University, Riyadh, Saudi Arabia. The FENO levels were measured by NIOX MINO (Aerocrine AB, Solna, Sweden), and ventilatory functions were recorded by standard techniques., Results: The FENO values were significantly higher in patients with an ACT score <20 (65.5+/= 35.4) compared with those patients with an ACT score >/= 20 (27.4+/=10.5, p<0.001). Among the well-controlled group based on the ACT score criteria, 6 (25%) cases had high FENO levels, while among the poorly controlled group, 23 (79.3%) cases had high FENO levels (odds ratio: 11.5; p<0.0001; confidence interval: 3.16-41.72). There was a significant negative correlation between FENO and ACT score (r=-0.581, p<0.0001). At the international cutoff point of 20, the sensitivity was 95.2, and the specificity was 68.8. The receiver operating curve (ROC) showed that maximum sensitivity and specificity were observed at an ACT score cut off point of 19 (sensitivity: 90.5, and specificity: 81.2)., Conclusion: The FENO levels correlate negatively with ACT scores however, the relationship between FENO and lung function is not significant. A significant relationship between ACT score and FENO levels indicate that there is an ongoing inflammatory state in patients with poor asthma control.

Objective: To assess the epidemiologic and clinical manifestations of the first wave of H1N1 influenza A patients., Methods: This study is a retrospective chart review of all patients admitted in King Saud Medical Complex, Riyadh, Kingdom of Saudi Arabia, from 22nd May to 31st August 2009, with a proven diagnosis of H1N1 influenza A. Only patients with a positive nasopharyngeal swab were included, and excluded when the swab was negative. Charts were then analyzed for epidemiological and clinical data., Results: A total of 153 patients with proven H1N1 infection were admitted, with a predominance of male patients (108 [71%]). Most patients were Saudis (111 [73%]), with 83 males (75%), and 28 females (25%). The mean age was 25 years (standard deviation; 9.45 years), and median age was 24 years. The most common symptoms in order of frequency were; fever (143 patients), cough (126 patients), sore throat (70 patients), headache (18 patients), shortness of breath (17 patients), myalgia (11 patients), diarrhea (9 patients), and vomiting (7 patients). Average duration of symptoms before admission was 3.55 days, and the average time of hospitalization was 4.8 days. Full recovery was obtained in 150 patients. Death occurred in 3 patients., Conclusion: True to its designation as a pandemic, H1N1 influenza A, has reached Saudi Arabia and poses a risk to the young population without immunity, and those with co-morbid disease, particularly of the lungs (bronchial asthma), and the pregnant. Despite its virulence in infecting people, deaths are far less than anticipated for such a novel virus. Social distancing can be recommended. However, further observation has to continue to substantiate these tentative preliminary findings.

Objective: To determine the reference values of the fraction of exhaled nitric oxide (FENO) among healthy, non-smoking male adults and its correlation with age, height, weight, and body mass index (BMI)., Methods: This cross-sectional study was conducted at the Departments of Physiology and Medicine, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, from September 2007 to August 2008 on healthy non-atopic, non-smoking male Saudi subjects. The FENO was measured online using the single-breath technique according to recent guidelines of the American Thoracic Society (ATS)., Results: We studied 121 subjects with a mean age of 31.00 +/- 12.24 years, BMI of 27.23 +/- 6.64, and FEV1/FVC 85% (81-92%). The FENO ranged between 7.66 parts per billion (ppb) and 46.6 ppb (mean 22.79 +/- 8.13), with >84% of subjects recording levels <30 ppb and >95% with levels <40 ppb. The FENO negatively correlated with body weight (r=0.3888, p=0.001) and BMI (r=0.238, p=0.009). No correlation was observed between FENO, FEV1/FVC ratio, age, and height., Conclusion: The reference values of FENO for non-smoking, non-atopic male Saudi adults fall between 7.66 and 46.6 ppb (mean 22.79 +/- 8.13), similar to other populations. The FENO negatively correlates with body weight and BMI.

Objective: Acute myocardial infarction (MI) is a major health problem with a substantial fatality and morbidity. The management of patients with acute MI has been addressed in major trials to improve the survival and enhance the quality of life of the patients. Numerous guidelines have been established for the management of such patients. The objective of this study is to determine whether the current practice in managing patients admitted with acute MI in a major community hospital in Riyadh is evidence based compliant., Methods: The data were collected from patients admitted to the Coronary Care Unit (CCU), Riyadh Medical Complex (RMC), Riyadh, Kingdom of Saudi Arabia, a 1500 bed community hospital, with a diagnosis of acute MI over one-year period (April 1999 to April 2000). The administration of different therapeutic modalities upon admission as well as discharge medications was obtained. Patients outcome (all cause mortality) post treatment were collected. The data was analyzed and compared with the current guidelines., Results: A total of 335 patients, 315 males (94%), were admitted to the CCU of RMC with a diagnosis of acute MI. Two hundred and seventy-one patients (80.9%) received thrombolytic therapy. Discharge medications were beta-blocker in 255 (76.1%), angiotensin converting enzyme inhibitors in 206 (61.5%), nitrates in 281 (83.9%), hypolipidemic agents in 15 patients (4.5%), and aspirin in all patients. The outcome of these patients obtained either alive or dead was 313 (93.4%) and 22 (6.6%) (p<0.00001)., Conclusion: The patients with acute MI received management compliant with evidence-based practice. However, more awareness to the use of angiotensin converting enzyme inhibitors as well as hypolipidemic agents is needed to provide maximum benefit to these patients. Moreover, national guidelines for the management of acute MI are needed for improvement of quality of care.

Objective: A large variety of disorders can lead to lymphadenopathy. It is important and beneficial to patient management to rapidly differentiate between benign and malignant causes. The objective of the study is to identify factors predicting nodal malignancy from readily available clinical data., Methods: A retrospective study was carried out on patients admitted to Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia between April 1996 and March 2000 with lymphadenopathy, who underwent lymph node biopsy., Results: Univariate analysis suggests 6 variables (age, sex, the presence of other physical signs, abnormal complete blood count, abnormal liver function test and negative Mantoux test) to have independent association with nodal malignancy. The multivariate logistic regression model revealed patients aged more than 40 years, males, generalized lymphadenopathy, presence of other physical signs, abnormal liver function tests and negative Mantoux test to be statistically significantly associated with nodal malignancy (p>0.05)., Conclusion: The present logistic model can be useful in predicting nodal malignancy using routinely collected clinical data.

An asymptomatic full term pregnant lady with a grossly abnormal chest radiograph is presented as a clinical quiz. The diagnosis is discussed and the topic reviewed in detail.

Objective: Thrombolytic therapy is a standard treatment for patients presenting with acute myocardial infarction (MI). Early administration of these agents is crucial for the outcome of management. This audit was conducted to evaluate the time between arrival to emergency department (ED) and the administration of thrombolysis (door to needle time)., Methods: Data was collected from patients admitted to the Coronary Care Unit of Riyadh Medical Complex (RMC), Riyadh, Kingdom of Saudi Arabia, a 1500-bed community hospital, with a diagnosis of acute MI and received thrombolytic therapy over a one-year period (April 1999 to April 2000). The time between arrival to the ED to the time of administration of thrombolytic therapy was obtained as well as the time of onset of chest pain up to presentation to the hospital, and the outcome (all cause mortality) post treatment., Results: A total of 271 patients (256 males) admitted to RMC with a diagnosis of acute MI received thrombolytic therapy over a one-year duration. The median door to needle time was 95 minutes. The median time of onset of chest pain to arrival to ED was 5 hours (300 minutes). The outcome of these patients obtained either alive was 260 (96%) or dead was 11 (4%) (P < 0.00001)., Conclusion: The door to needle time was relatively similar to other centers. The delay in administering thrombolytic therapy should be reduced to a target of <70 minutes from onset of symptoms. Delay in presentation to the hospital was more important and factors contributing to this delay should be looked for and corrected. Another audit is needed to evaluate the implementation of these recommendations.

Objective: The aim of this study is to describe the clinical and imaging features of Swyer-James-Macleod syndrome (SJMS) in 9 adults., Methods: We reviewed the charts of 9 patients diagnosed with SJMS at the King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia over a 10 year period., Results: The patients mean age was 38.1 years; males were more affected than females (7:2). Seven of the patients had symptoms referable to the chest and a similar number had compatible abnormalities on physical examination. The left lung was involved in all cases. Bronchiectasis was present in 7 (77.8%). Eight patients who underwent pulmonary function tests had combined defects. Two patients demonstrated significant reversibility. All patients had a stable course over at least before a 3 year follow-up period., Conclusion: Swyer-James-Macleod syndrome has a diverse manifestations in adults and can mimic other pulmonary disorders, which may lead to incorrect diagnosis and inappropriate therapy. The course is generally a stable one.

Objective: To study the use of oxygen therapy on the medical wards in 2 hospitals in Riyadh, Kingdom of Saudi Arabia. One was academic, King Khalid University Hospital and the other a community hospital, Riyadh Medical Complex., Methods: This study was carried out over a one year period, 6 April 2000 through to 6 April 2001. Oxygen saturation was measured randomly by pulse oximetry in patients receiving oxygen therapy. Charts of the patients were inspected for relevant information related to oxygen therapy, including indications, dose, monitoring and documentation of the order. If oxygen saturation was >97% oxygen flow was reduced to maintain oxygen saturation between 92% and 94%. The potential savings by such reduction were calculated., Results: A total of 108 patients were studied. The most frequent indications for oxygen therapy were hypoxemia and dyspnea. Arterial oxygen tension before starting oxygen was carried out for 78 patients (72.2%) and showed that the majority (60 patients, 76.9%) were hypoxemic arterial oxygen tension <= 65 mm Hg). The last documented arterial oxygen tension values after initiating oxygen were found in 79 patients (73.1%) and these were carried out at mean interval of 111 hours (range one-1200) before our assessment. Most patients (32 patients, 40.5%) had excessive values (>85 mmHg), 24 patients (30.4%) were hypoxemic (arterial oxygen tension <=65 mmHg) and only 23 patients (29.1%) had acceptable values (arterial oxygen tension > 65-85 mmHg). Our measurements also showed that arterial oxygen tension was excessive (>97%) in 59 patients (54.6%), adequate (>=92%-97%) in 44 patients (40.7%), and only a minority (5 patients, 4.6%) were hypoxemic (<92%). Oxygen dose could be reduced in 31 patients (28.7%) by a mean of 42% (range 18%-66%) and stopped in 38 patients (35%) while maintaining aterial oxygen tension between 92%-94%. Errors in oxygen prescription were more apparent in the non-academic setting (P<0.05%)., Conclusion: Oxygen prescription was sub-optimal in both the academic and non-academic setting. The study highlights the need to adopt and evaluate cost-effective measures such as oxygen titration protocols using pulse oximetry, and physician education programs.

Objective: To describe the clinicopathological features of patients admitted to adult wards with a primary presenting feature of lymphadenopathy., Methods: A retrospective study of all patients admitted to Riyadh Medical Complex, Riyadh, Kingdom of Saudi Arabia between April 1996 through to March 2000., Results: The patients mean age was 35.2 years (standard deviation 15.7 years) and 59.5% were females while 56.2% were Saudis. Swelling was the primary presenting symptom in 39.3% of the patients, while fever, night sweats, and pain occurred in 17.3%, 10.3% and 8.5% patients. There was considerable overlap between benign and malignant causes of lymphadenopathy but in 56.6% of patients, lymphadenopathy was the only sign. The cervical group of lymph nodes was the most commonly affected site. Hepatomegaly, splenomegaly and both organ enlargement occurred in 59 (22.9%) patients. The presence of generalized lymphadenopathy and other physical signs (serositis and organomegaly) highly suggested a malignant process. Granulomatous lymphadenopathy due to tuberculosis was the most frequent pattern 98 (37.9%) followed by lymphoma 85 (32.9%). Tuberculosis was also more common in females than males (51% versus 19%). Among patients with Hodgkin's disease, nodular sclerosis was the most frequent (75%). Routine investigations did not discriminate between benign and malignant causes of lymphadenopathy. The overall mortality rate was 8.1%: with metastatic disease accounting for 52.4%., Conclusion: There were significant similarities and differences between these findings and other previous studies in the Kingdom of Saudi Arabia and elsewhere.