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Abdullah AL-Harbi,1– 3 Tammam Alanazi,1 Hazim Alghamdi,1 Meshal Alberreet,1 Abdulaziz Alkewaibeen,1 Abdulrahman Alkhalifah,1 Aamir Omair,1,4 Mohammad Khan,1– 3 Hamdan AL-Jahdali1– 3 1College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 2Department of Medicine, Pulmonary Division, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia; 3King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; 4Department of Medical education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaCorrespondence: Abdullah AL-HarbiDepartment of Medicine, Pulmonary Division, Ministry of National Guard-Health Affairs, P.O. Box 22490, MC 1443, Riyadh, 11426, Saudi Arabia, Email harbia7@ngha.med.sa; draalharbi@yahoo.comBackground: Insomnia is commonly reported in patients with asthma. However, the prevalence of insomnia and its relationship to asthma control have not been established.Objective: To determine the prevalence of insomnia in adults with asthma and to evaluate the association between insomnia and level of asthma control.Methods: This is a cross-sectional study of 200 patients recruited from pulmonary clinics at a tertiary care center. Adults (age ≥ 16 years) diagnosed with asthma by the primary treating physician were recruited over a 6-month period from December 2018 to May 2019. Asthma and insomnia severity were assessed using the Asthma Control Test and Insomnia Severity Index (ISI).Results: The mean age of participants was 51± 17 years, and 67% were female. Insomnia (ISI score ≥ 10) was present in 46.5% of the participants. The severity of insomnia was inversely related to the level of asthma control: moderate-to-severe insomnia was more frequent in patients with uncontrolled asthma (43%) than in those with partially controlled asthma (25%) or well-controlled asthma (12%) (P < 0.05 for all comparisons).Conclusion: Insomnia is common among patients with asthma, especially those with suboptimal asthma control. Further investigations are required to more fully understand the complex relationship between asthma and insomnia.Keywords: prevalence, asthma, insomnia, asthma control, Insomnia Severity Index

Abdullah AL-Harbi,1– 3 Majed AL-Ghamdi,1– 3 Mohammad Khan,1– 3 Sulaiman AL-Rajhi,1,3,4 Hamdan AL-Jahdali1– 3 1College of Medicine, King Saud University for Health Sciences, Riyadh, Saudi Arabia; 2Department of Medicine, Pulmonary Division, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia; 3King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; 4Department of Medical Imaging, Ministry of National Guard-Health Affairs, Riyadh, Saudi ArabiaCorrespondence: Abdullah AL-HarbiDepartment of Medicine, Pulmonary Division, Ministry of National Guard-Health Affairs, King Abdulaziz Medical City, PO Box 22490, MC 1443, Riyadh 11426, Saudi ArabiaEmail harbia7@ngha.med.saObjective: The aim of this study was to assess the clinical characteristics and outcomes of patients with post‐tuberculosis (post-TB) bronchiectasis. We also evaluated the performance of various multidimensional severity score systems to predict mortality, future exacerbation, and hospitalization.Methods: We conducted a prospective observational cohort study to evaluate the etiology of bronchiectasis in 301 patients. Patients fell into three groups: post-TB (129 [43%]), idiopathic (76 [25%]), and other (96 [32%]) etiologies of bronchiectasis. Four multidimensional grading scales, including the Bronchiectasis Severity Index (BSI), the FACED score, and two derivative versions of the FACED score, Exacerbation (Exa-FACED and E-FACED), were calculated and compared for each patient.Results: Patients with post-TB bronchiectasis were predominantly female (61%) with a mean age of 68± 11 years. Moreover, 26% of post-TB bronchiectasis patients were colonized with Pseudomonas aeruginosa. At baseline, patients with post-TB bronchiectasis were older, had higher severity scores, and were more likely to have experienced severe exacerbations that required hospitalization compared to patients with idiopathic bronchiectasis or bronchiectasis arising from other causes. During follow-up, 52% of patients required hospitalization, 58% had frequent (≥ 2 per year) acute exacerbations, and the overall 5-year mortality rate was 30%. Five-year survival was efficiently predicted by each of the grading scales. Although the modified variations of the FACED outperformed the original FACED scale in predicting forthcoming frequent acute exacerbations and hospitalization, the BSI outperformed all three systems in this regard.Conclusion: Patients with post-TB bronchiectasis had higher severity scores than patients with idiopathic bronchiectasis or bronchiectasis arising from other causes. In addition, all scoring systems performed adequately in 5-year mortality projections. BSI and the modified versions of the FACED outperformed the FACED in predicting forthcoming exacerbations and hospitalizations.Keywords: bronchiectasis, post-TB bronchiectasis, Bronchiectasis Severity Index, BSI, FACED score, acute exacerbation, hospitalization, Exacerbation-FACED score, Exa-FACED score, E-FACED score

Anwar E Ahmed,1 Mody Alaqeel,2 Naif A Alasmari,3 Hoda Jradi,2 Hazza Al Otaibi,2 Oraynab A Abbas,3 Mesnad Alyabsi,4 Adel F Almutairi,4 Ada Al-Qunaibet,5 Hamdan Al-Jahdali2 1Uniformed Services University of the Health Sciences, F. Edward Hébert School of Medicine, Department of Preventive Medicine & Biostatistics, Bethesda, Maryland, USA; Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA; 2King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 3Ministry of Health, Riyadh, Saudi Arabia; 4King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; 5Saudi Center for Disease Prevention and Control, Riyadh, Saudi ArabiaCorrespondence: Anwar E AhmedUniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USATel +1 (301) 400-4356Email anwar.ahmed.ctr@usuhs.eduIntroduction: Although the incidence of suicide attempts continues to increase among youth in Saudi Arabia, no risk assessment tool has been established for suicide attempt repetition in the country’s youth population. The objective of the study was to develop risk assessment of suicide attempt repetition among youth in Saudi Arabia.Methods: This is a retrospective study of youth (10– 24 years) with intentional suicide attempt(s) who presented to the emergency departments (ED) at King Abdullah Specialist Children’s Hospital (KASCH) and King Abdulaziz Medical City-Riyadh (KAMC-R), Saudi Arabia between 1 January 2015 and 31 December 2017. We excluded youth having unintentional suicide attempts. Data were retrieved for the 157 eligible as having attempted suicide.Results: Forty-one of 157 (26.1%) had repeated suicide attempts (95% confidence limits: 19.433.7%). Four independent factors were identified that were associated with an increased risk of repeated suicide attempts: age (adjusted odds ratio [aOR] = 1.147, 95% confidence interval (CI) = 11.015– 1.297, P=0.028), family problems (aOR = 4.218, 95% CI = 1.690– 10.528, P=0.002), psychiatric disorders (aOR = 3.497, 95% CI = 1.519– 8.051, P=0.003), and hospitalization (aOR = 5.143, 95% CI = 1.421– 18.610, P=0.013). This risk model showed adequate utility with an area under the receiver operating characteristic (ROC) curve (AUC): 77.9%, 95% CI: 69.486.3% with optimism-corrected AUC = 71.8%. Youden index defined a probability of ≥ 0.38 to predict a high risk of repeated suicide attempts.Conclusion: The risk of repeated suicide attempts among Saudi youth was high, compatible with what has been reported among youth in England and in France. Age, family problems, psychiatric disorders, and hospitalization are risk factors for repeated suicide attempts. A prevention program for suicide attempts in youth may take into account family problems, screening for psychiatric disorders, and suicidal behavior.Keywords: repeated suicide attempts, psychiatric disorders, family problems, youth

Anwar E Ahmed,1,2 Donna K McClish,3 Thamer Alghamdi,4 Abdulmajeed Alshehri,4 Yasser Aljahdali,4 Khalid Aburayah,4 Abdulrahman Almaymoni,4 Monirah Albaijan,1 Hamdan Al-Jahdali,1,4–6 Abdul Rahman Jazieh4–6 1King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia; 2College of Public Health and Health Informatics, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 3Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA; 4College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 5King Abdulaziz Medical City, Riyadh, Saudi Arabia; 6Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia Background: Despite the continuing increase in the breast cancer incidence rate among Saudi Arabian women, no breast cancer risk-prediction model is available in this population. The aim of this research was to develop a risk-assessment tool to distinguish between high risk and low risk of breast cancer in a sample of Saudi women who were screened for breast cancer.Methods: A retrospective chart review was conducted on symptomatic women who underwent breast mass biopsies between September 8, 2015 and November 8, 2017 at King Abdulaziz Medical City, Riyadh, Saudi Arabia.Results: A total of 404 (63.8%) malignant breast biopsies and 229 (36.2%) benign breast biopsies were analyzed. Women ≥40 years old (aOR: 6.202, CI 3.497–11.001, P=0.001), hormone-replacement therapy (aOR 24.365, 95% CI 8.606–68.987, P=0.001), postmenopausal (aOR 3.058, 95% CI 1.861–5.024, P=0.001), and with a family history of breast cancer (aOR 2.307, 95% CI 1.142–4.658, P=0.020) were independently associated with an increased risk of breast cancer. This model showed an acceptable fit and had area under the receiver-operating characteristic curve of 0.877 (95% CI 0.851–0.903), with optimism-corrected area under the curve of 0.865.Conclusion: The prediction model developed in this study has a high ability in predicting increased breast cancer risk in our facility. Combining information on age, use of hormone therapy, postmenopausal status, and family history of breast cancer improved the degree of discriminatory accuracy of breast cancer prediction. Our risk model may assist in initiating population-screening programs and prompt clinical decision making to manage cases and prevent unfavorable outcomes. Keywords: breast cancer management, risk assessment, modeling, patient stratification, predictive tool

Anwar E Ahmed,1,2 Alhanouf N Albalawi,3 Eiman T Qureshey,3 Aisha T Qureshey,3 Nagarajkumar Yenugadhati,2 Hamdan AL-Jahdali,4 Abdul Rahman Jazieh5 1King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia; 2College of Public Health and Health Informatics, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 3Riyadh Elm University, Riyadh, Saudi Arabia; 4College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 5Department of Oncology, King Abdulaziz Medical City for National Guard, Ministry of National Guard, Riyadh, Saudi Arabia Background: Although psychological symptoms and oral health status are associated with health management and outcomes among cancer patients, their association has not been assessed in Saudi Arabia. We aimed to assess the symptoms of depression, anxiety, and stress and their association with their oral health status, adjusting for sociodemographic and clinical factors. Methods: A self-reported study included 375 adult cancer patients who received outpatient healthcare services in the Oncology Department, King Abdulaziz Medical City-Riyadh, Saudi Arabia, between April 1 and August 31, 2017. We used the Arabic version of the Depression Anxiety Stress Scale to dichotomize a binary outcome for each. Oral health was evaluated by self-rating from “very good” to “bad”.Results: A high prevalence of subjective depression, anxiety, and stress was found (44.8%, 52.5%, and 42.7%, respectively). Of the sample, 17.9% self-reported “bad” oral health, which is associated with a high risk of anxiety and stress, and its association remains significant after controlling for other factors (adjusted odds ratio=6.48 and 4.73, respectively). Being

Anwar E Ahmed,1,2 Faris S Alzahrani,2 Ahmed M Gharawi,2 Salman A Alammary,2 Fahad H Almijmaj,2 Fahad M Alhusayni,2 Donna K McClish,3 Hamdan Al-Jahdali,1,2 Ashwaq A Al Olayan,4 Abdul Rahman Jazieh4 1King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia; 2King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 3Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA; 4King Abdulaziz Medical City, National Guards Health Affairs, Riyadh, Saudi Arabia Background: Imaging tests used in our center are usually inadequate to confirm the high risk for pancreatic cancer. We aimed to use a combination of potential predictors including imaging tests to quantify the risk of pancreatic cancer and evaluate its utility. Methods: This was a retrospective cohort study of patients who were suspected as having pancreatic cancer and underwent biopsy examination of pancreatic mass at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between January 1, 2013, and December 31, 2016. We retrieved data on demographics, clinical history, imaging tests, and final pancreatic diagnosis from medical records. Results: Of the 206 who underwent pancreatic biopsies, the mean age was 63.6 years; 54.4% were male. Of all the biopsies, 57.8% were malignant and 42.2% were benign masses. Nine factors contributed significantly to the risk of pancreatic cancer and were noted: older age (adjusted odds ratio [aOR] =1.048; P=0.010), male gender (aOR =4.670; P=0.008), weight loss (aOR =14.810; P=0.001), abdominal pain (aOR =7.053; P=0.0.001), blood clots (aOR =20.787; P=0.014), pancreatitis (aOR =4.473; P=0.021), jaundice (aOR =7.446; P=0.003), persistent fatigue (aOR =22.015; P=0.015), and abnormal imaging tests (aOR =67.124; P=0.001). The model yielded powerful calibration (P=0.953), excellent predictive utility (area under the receiver operating characteristic curve 96.3%; 95% CI =94.1, 98.6), with optimism-corrected area under the curve bootstrap resampling of 94.9%. An optimal cut-off risk probability of 0.513 yielded a sensitivity of 94% and specificity of 84.7% for risk classification. Conclusion: The study developed and validated a risk model for quantifying the risk of pancreatic cancer. Nine characteristics were associated with increased risk of pancreatic cancer. This risk assessment model is feasible and highly sensitive and could be useful to improve screening performance and the decision-making process in clinical settings in Saudi Arabia. Keywords: pancreas, cancer, fatigue, weight loss, blood clots, jaundice, Saudi Arabia

Anwar E Ahmed,1,2 Doaa A AlBuraikan,2 Hend R Almazroa,2 Manair N Alrajhi,2 Bashayr I ALMuqbil,2 Monirah A Albaijan,1 Majid A Alsalamah,2 Hamdan AL-Jahdali1,2 1King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia; 2King Saud bin Abdulaziz University for Health Sciences, National Guard Health Affairs, Riyadh, Saudi Arabia Background: Despite the increase in adult emergency department (ED) utilization in Saudi Arabia, no studies have evaluated the 72-hour revisits. This study estimates the rate of 72-hour ED revisits and identifies its reasons and predictive factors among adults with chronic diseases. Patients and methods: A hospital-based retrospective study that included 24,206 ED discharges for adults with chronic diseases at the adult ED of King Abdulaziz Medical City, Riyadh between September 13, 2015 and July 29, 2017 was performed. We extracted data on demographic information, reasons for ED visits/revisits, health insurance coverage, weekend ED arrival, and mortality. Results: A sample of 24,206 ED discharges for 19,697 adults with at least one chronic disease was included in the analysis. The rate of 72-hour revisits in this study population was high: 3,144/24,206 (13%) had the first revisit and 319/3,144 (10.1%) had the second ED revisit within 72 hours. Diseases of the circulatory (19%) and genitourinary (15.8%) systems were the major reasons for the first ED revisit. The adjusted relative rate (aRR) of 72-hour ED revisits was higher in adults with chronic diseases and aged ≥60 years (aRR=1.360, 95% CI: 1.41–1.83; P=0.001), patients of female gender (aRR=1.24, 95% CI: 1.09–1.41; P=0.001), patients with health insurance coverage (aRR=4.23, 95% CI: 2.60–6.90; P=0.001), patients arriving to ED on a weekend (aRR=2.13, 95% CI: 1.03–4.41; P=0.041), and new patients (aRR=1.47, 95% CI: 1.25–1.73; P=0.001). Conclusion: The rate of 72-hour revisits is high among adults with chronic diseases. Advancing age, female gender, health insurance coverage, weekend ED arrival, and new patients are the important predictive factors of the high rate of 72-hour revisits. Continuous quality assessment and monitoring of factors related to patients are needed to reduce the frequency of early ED revisits after discharge. Keywords: 72-hour ED revisits, emergency department, KAMC, Saudi Arabia

Anwar E Ahmed,1,2 Wala R Alanazi,3 Rayan A Ahmed,4 Wijdan AlJohi,2 Doaa A AlBuraikan,2 Budor A AlRasheed,2 Bashayr I ALMuqbil,2 Ali A Al-Zahrani,2,5 Zeyad M Yousef,2,5 Hamdan AL-Jahdali2,5 1King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia; 2King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 3Al-Maarefa College for Science and Technology, Riyadh, Saudi Arabia; 4Dar Al Uloom University, Riyadh, Saudi Arabia; 5King Abdulaziz Medical City, Riyadh, National Guard Health Affairs, Riyadh, Saudi Arabia Background: Although the frequency of surgical weight loss interventions has increased in Saudi Arabia, literature describing the clinical outcomes of bariatric surgery in Saudi Arabia is limited. This study aimed to assess whether weight loss intervention improves hemoglobin A1c (HbA1c) in obese patients and to identify its associated factors.Patients and methods: A retrospective study was carried out on 318 patients with obesity class 1 or higher (body mass index [BMI] ≥ 30 kg/m2) who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass at King Abdulaziz Medical City in Riyadh, Saudi Arabia, between January 1, 2001 and March 31, 2017. Preoperatively and 12 months postoperatively, characteristics of patients were collected. BMI reduction was calculated, based on which patients were divided into three groups (0–9, 10–14, and >14 kg/m2).Results: The postoperative HbA1c was 5.83±0.9, while the baseline level was 6.74±2.1 (P=0.001). Fifty-eight of the 318 patients had diabetes. We observed significantly higher HbA1c in diabetic than in non-diabetic patients preoperatively, whereas an insignificantly ­different HbA1c was observed postoperatively. Among those who had minimal reduction in BMI (0–9 kg/m2), we observed significantly higher HbA1c in diabetic than in non-diabetic patients, whereas among those who had large reduction in BMI (10–14 kg/m2) and (>14 kg/m2), we observed insignificant differences in HbA1c in diabetic than in non-diabetic patients.Conclusion: Being a diabetic patient was related to a significant reduction in HbA1c levels postoperatively. The study suggests that the reduction in HbA1c levels could be modified by BMI, wherein greater reduction in BMI leads to greater reduction in HbA1c levels. Keywords: HbA1c, diabetes, weight loss surgery, BMI, morbid obese, sleeve

Nagarajkumar Yenugadhati,1,2 Alhanouf Naji Albalawi,3 Aisha Taha Qureshey,3,* Eiman Taha Qureshey,3,* Hamdan Al-Jahdali,4 Abdul Rahman Jazieh,5 Anwar E Ahmed1,2 1King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard, Riyadh, Saudi Arabia; 2College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard, Riyadh, Saudi Arabia; 3Riyadh Elm University, Riyadh, Saudi Arabia; 4Department of Medicine, Pulmonary Division-ICU, King Saud bin Abdulaziz University for Health Sciences, Ministry of National Guard, Riyadh, Saudi Arabia; 5Department of Oncology, King Abdulaziz Medical City for National Guard, Ministry of National Guard, Riyadh, Saudi Arabia *These authors contributed equally to this work Purpose: Oral health in cancer patients was known to influence the quality of life. However, the knowledge of possible factors associated with oral health in cancer patients is seriously lacking in Saudi Arabia. In this study, we aimed to determine the burden of adverse oral health in cancer patients and identify the associated factors for oral health problems. Materials and methods: A cross-sectional study design was used to recruit a total of 375 cancer patients who attended oncology outpatient clinics at King Abdulaziz Medical City – Riyadh (KAMC-R) by using a consecutive sampling technique. A self-reporting questionnaire was used to collect the sociodemographic information, clinical symptoms, and lifestyle factors of cancer patients. Furthermore, depression, anxiety, and stress were assessed by using Depression Anxiety and Stress Scale. The authors assessed the oral health complaints based on seven common conditions (bleeding gums, toothache, mouth ulcers, bruxism, xerostomia, problems affecting speech, and satisfactory dietary intake). Unadjusted and adjusted risk ratios (aRR) and 95% CIs for the factors associated with the number of oral complaints experienced were computed using Poisson regression model. Results: The prevalence of oral health conditions experienced by cancer patients was 86.1% (95% CI: 82.2%–89.5%). Female sex (aRR=1.37, 95% CI: 1.05–1.78), low income (aRR=1.58, 95% CI: 1.23–2.04), smoking (aRR=1.29, 95% CI: 1.02–1.64), anxiety (aRR=1.75, 95% CI: 1.36–2.24), and stress (aRR=1.25, 95% CI: 1.00–1.55) were associated with increased risk of oral health problems in cancer patients (p≤0.05), whereas breast cancer patients experienced reduced risk (aRR=0.72, 95% CI: 0.56–0.93). Conclusion: Our study highlighted the significant burden of oral health problems in Saudi cancer patients at KAMC-R and identified several key associated factors for oral health to aid healthcare practitioners in improving cancer management practices. Keywords: oral health, cancer survivors, prevalence, associated factors

Anwar E Ahmed,1 Yosra Z Ali,2 Ahmad M Al-Suliman,3 Jafar M Albagshi,3 Majid Al Salamah,1 Mohieldin Elsayid,1 Wala R Alanazi,4 Rayan A Ahmed,5 Donna K McClish,6 Hamdan AL-Jahdali,1,2 1College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 2King Abdulaziz Medical City, Riyadh, Saudi Arabia; 3King Fahad Hospital, Hofuf, Saudi Arabia; 4Al-Maarefa College for Science and Technology, Riyadh, Saudi Arabia; 5Dar Al Uloom University, Riyadh, Saudi Arabia; 6Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA Introduction: High white blood cell (WBC) count is an indicator of sickle cell disease (SCD) severity, however, there are limited studies on WBC counts in Saudi Arabian patients with SCD. The aim of this study was to estimate the prevalence of abnormal leukocyte count (either low or high) and identify factors associated with high WBC counts in a sample of Saudi patients with SCD. Methods: A cross-sectional and retrospective chart review study was carried out on 290 SCD patients who were routinely treated at King Fahad Hospital in Hofuf, Saudi Arabia. An interview was conducted to assess clinical presentations, and we reviewed patient charts to collect data on blood test parameters for the previous 6 months. Results: Almost half (131 [45.2%]) of the sample had abnormal leukocyte counts: low WBC counts 15 (5.2%) and high 116 (40%). High WBC counts were associated with shortness of breath (P=0.022), tiredness (P=0.039), swelling in hands/feet (P=0.020), and back pain (P=0.007). The mean hemoglobin was higher in patients with normal WBC counts (P=0.024), while the mean hemoglobin S was high in patients with high WBC counts (P=0.003). After adjustment for potential confounders, predictors of high WBC counts were male gender (adjusted odds ratio [aOR]=3.63) and patients with cough (aOR=2.18), low hemoglobin (aOR=0.76), and low heart rate (aOR=0.97). Conclusion: Abnormal leukocyte count was common: approximately five in ten Saudi SCD patients assessed in this sample. Male gender, cough, low hemoglobin, and low heart rate were associated with high WBC count. Strategies targeting high WBC count could prevent disease complication and thus could be beneficial for SCD patients. Keywords: white blood cell, leukocyte, SCD, Saudi, hemoglobin, low heart rate, Saudi Arabia

Imad Salah Hassan, Hadi Kuriry, Lina Al Ansari, Ali Al-Khathami, Mohammed Al Qahtani, Thari Al Anazi, Mahfooz Farooqui, Hamdan Al Jahdali Department of Medicine 1443, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia Abstract: Outcome-focused, competency-based educational curricula have become the norm in residency training programs. The Canadian Medical Education Directives for Specialists (CanMEDS) framework is one example of such a curriculum. However, models for incorporating all the competencies in everyday clinical practice have been difficult to accomplish. In this manuscript, a CanMEDS, competency-structured, acute case discussion in a regular morning meeting was undertaken. All the diagnostic and therapeutic interventions were explicitly organized and discussed under their respective CanMEDS competency headings. Post exercise, the majority of residents felt that they were more competent in all the competencies and indicated their willingness to continue having similarly structured acute case discussions in the future. Keywords: CanMEDS roles, residents, morning meeting

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Background: Treatment of latent tuberculosis infection with isoniazid for 9 months is complicated by poor patient adherence and the need for close follow-up of side effects, especially hepatotoxicity. Shorter and safer regimens are needed.Objective: To compare the frequency of adverse events and treatment completion in 2 treatment regimens for latent tuberculosis infection.Design: Multicenter, randomized, open-label trial.Setting: Tuberculosis clinics located in university hospitals in Canada, Brazil, and Saudi Arabia.Patients: 847 patients without a contraindication for rifampin and requiring treatment for latent tuberculosis infection.Intervention: Four months of daily rifampin therapy or 9 months of daily isoniazid therapy.Measurements: Grade 3 to 4 drug-related adverse events resulting in drug discontinuation (primary outcome), and on-time treatment completion, grade 1 to 2 drug-related adverse events, and changes in liver enzymes and hematologic variables (secondary outcomes).Results: Seventeen of 422 participants who started isoniazid therapy developed grade 3 to 4 adverse events compared with 7 of 418 who started rifampin therapy (risk difference [rifampin minus isoniazid], -2.3% [95% CI, -5% to -0.1%]; P = 0.040). Grade 3 or 4 hepatitis occurred in 16 of 422 isoniazid recipients compared with 3 of 418 rifampin recipients (risk difference, -3.1% [CI, -5% to -1%]; P = 0.003). Grade 1 or 2 adverse events attributed to study drugs occurred with similar frequency. Asymptomatic reduction in platelet and leukocyte counts were more frequent in rifampin recipients. More patients completed rifampin treatment (78%) than isoniazid treatment (60%) (difference, 18% [CI, 12% to 24%]; P < 0.001]).Limitation: The study did not measure efficacy, and the open-label design may increase the chance of bias in ascertainment of adverse events.Conclusion: Treatment of latent tuberculosis with 4 months of rifampin leads to fewer serious adverse events and better adherence than 9 months of isoniazid. These findings justify a large-scale trial to compare the efficacy of rifampin with that of isoniazid. [ABSTRACT FROM AUTHOR]

Tuberculin skin test (TST) interpretation can be confounded by Bacillus Calmette-Guerin (BCG) vaccination and infection with nontuberculosis mycobacteria (NTM). However, a wealth of epidemiologic information has allowed the formulation of recommendations for reasonably informed interpretation of the TST in most clinical situations. In the Middle East, the TST remains a useful test. BCG vaccination is given at birth, which should have minimal effect on TST reactions in adolescents or adults. In countries of the Middle East with moderate to high incidence of active smear-positive pulmonary TB (>20 per 100,000 per year), a positive TST will almost always indicate true TB infection. However, in Middle East countries with very low incidence of active TB (<10 per 100,000 per year), a positive TST will more likely be false positive because BCG vaccination is still routinely given; until BCG vaccination is abandoned, the TST will be less useful in these countries. These findings are applicable to countries in other regions of the world, and the utility TST will also be increased where the likelihood of TB infection is higher and lowered where TB infection is unlikely, yet BCG vaccination is still given. [ABSTRACT FROM AUTHOR]

Background/propose: Sleep disturbance and excessive daytime sleepiness (EDS) have been reported in patients with hepatic cirrhosis with no hepatic encephalopathy (HE). The objective of this study was to evaluate daytime sleepiness and risk of obstructive sleep apnea (OSA) among liver cirrhosis patients. Material and methods: A cross-sectional study was conducted at King Abdulaziz Medical City (KAMC)-Riyadh over a period of six months, using a structured questionnaire that investigated: 1) Sleep patterns and daytime sleepiness using the Epworth Sleeping Scale (ESS), and 2) The risk for sleep apnea using the Berlin Questionnaire (BQ). We enrolled patients with a confirmed diagnosis of liver cirrhosis who were being followed at the hepatology and preliver transplant clinics. Results. We enrolled 200 patients with liver cirrhosis, 57.5% of whom were male. The mean age was 60 (± SD 12.2). The reported prevalence of EDS, OSA, and both EDS and OSA were 29.5%, 42.9%, and 13.6%, respectively. The prevalence of EDS was higher in patients with Hepatitis-C and patients with DM, who experienced short sleep duration. We did not find any association between the severity of liver disease and EDS or OSA as measured by Child-Pugh scores (CPS). Conclusions. The risk of OSA and EDS is high among liver cirrhosis patients. Those patients with cirrhosis secondary to Hepatitis C are at higher risk of EDS and OSA. Both EDS and OSA affect patients designated as CPS Class A more frequently than patients designated as CPS Class B.

Background: The utility of QuantiFERON-TB Gold In-Tube (QFT-G) test in the diagnosis of tuberculosis disease has been validated in high and low tuberculosis-prevalent (TB) countries. Aim: The aim of this study is to assess the performance of the QFT-G test in the diagnosis of tuberculosis disease among tuberculosis patients in an intermediate prevalent country. Setting and Design: A retrospective study at the King Abdulaziz Medical City-Riyadh (KAMC-R) Materials and Methods: We retrospectively reviewed all the patients with a diagnosis of pneumonia, including tuberculosis, admitted to KAMC-R between 1 January 2009 and 31 December 2013. We included only patients with an available result of the QFT-G test. A total of 142 tuberculosis cases and 226 pneumonia cases were studied, to assess the utility of the QFT-G test in diagnosing tuberculosis cases. Results: Among the tuberculosis (n = 142) cases, the QFT-G tested positive in 68.3%, negative in 23.2%, and indeterminate in 12 cases (8.5%). Of the 226 pneumonia cases, the QFT-G tested positive in only 20.4%, while a majority of 66.4% tested negative, with 30 cases (13.3%) being indeterminate. When we excluded 42 patients with indeterminate results, the QFT-G test achieved a sensitivity of 74.6% [95% CI: 66.09 to 81.65%] and specificity of 76.53 % [95% CI: 69.85 to 82.15%] in the diagnosis of tuberculosis cases. Conclusions: This study concludes that the QFT-G test is a useful tool for detecting tuberculosis disease when used as an adjunct tool for the diagnosis of active TB cases. It certainly cannot be used solely and indiscriminately, separate from other clinical and radiological information, in the diagnosis of active tuberculosis cases.

Acute pulmonary schistosomiasis affects non-immune individuals returning from endemic areas. Pathogenesis is not well understood. We report a case of acute pulmonary schistosomiasis in which lung biopsy was done 10 weeks after exposure and it identified the presence of schistosomal ovum surrounded by granuloma. [ABSTRACT FROM AUTHOR]

To review the pathogenesis of pulmonary vascular complications of liver disease, we discuss their clinical implications, and therapeutic considerations, with emphasis on potential reversibility of the hepatopulmonary syndrome after liver transplantation. In this review, we also discuss the role of imaging in pulmonary vascular complications associated with liver disease.

Advances in our understanding of human immunodeficiency virus (HIV) infection have led to improved care and incremental increases in survival. However, the pulmonary manifestations of HIV/acquired immunodeficiency syndrome (AIDS) remain a major cause of morbidity and mortality. Respiratory complaints are not infrequent in patients who are HIV positive. The great majority of lung complications of HIV/AIDS are of infectious etiology but neoplasm, interstitial pneumonias, Kaposi sarcoma and lymphomas add significantly to patient morbidity and mortality. Imaging plays a vital role in the diagnosis and management of lung of complications associated with HIV. Accurate diagnosis is based on an understanding of the pathogenesis of the processes involved and their imaging findings. Imaging also plays an important role in selection of the most appropriate site for tissue sampling, staging of disease and follow-ups. We present images of lung manifestations of HIV/AIDS, describing the salient features and the differential diagnosis.

The current cross sectional study is based on a questionnaire database on patients with end-stage renal disease (ESRD) to determine their preferences about end-of-life care and differences of certainty regarding the application of cardiopulmonary resuscitation and life sus-taining measures in case of cardiac arrest. The study was performed on 100 patients on hemo-dialysis for at least 2 years and not on the transplant list in two tertiary hospitals in Saudi Arabia; King Fahad National Guard in Riyadh and King Faisal Specialist Hospital in Jeddah in March 2007. More than two thirds of the surveyed patients were willing to make decisive decisions. Ha-ving more than 5 children was the only factor significantly associated with the ability to make de-cisive decisions; there was an insignificant association with factors such as marital status or non-Saudi nationality. Factors such as self-perception or disease curability, previous admissions to hospital or intensive care units, prior knowledge of mechanical ventilation, or cardiopulmonary resuscitation did not have any influence on making certain decisions on end-of-life care. There was a significant lack of knowledge in our study patients of cardiopulmonary resuscitation, me-chanical ventilation, and disease outcome.

The aim of this review is to present a pictorial essay emphasizing the various patterns of calcification in pulmonary nodules (PN) to aid diagnosis and to discuss the differential diagnosis and the pathogenesis where it is known. The imaging evaluation of PN is based on clinical history, size, distribution and the gross appearance of the nodule as well as feasibility of obtaining a tissue diagnosis. Imaging is instrumental in the management of PN and one should strive not only to identify small malignant tumors with high survival rates but to spare patients with benign PN from undergoing unnecessary surgery. The review emphasizes how to achieve these goals. One of the most reliable imaging features of a benign lesion is a benign pattern of calcification and periodic follow-up with computed tomography showing no growth for 2 years. Calcification in PN is generally considered as a pointer toward a possible benign disease. However, as we show here, calcification in PN as a criterion to determine benign nature is fallacious and can be misleading. The differential considerations of a calcified lesion include calcified granuloma, hamartoma, carcinoid, osteosarcoma, chondrosarcoma and lung metastases or a primary bronchogenic carcinoma among others. We describe and illustrate different patterns of calcification as seen in PN on imaging.

To determine the resuscitation preferences of hemodialysis (HD) Saudi patients, we con-ducted a cross-sectional, observational descriptive questionnaire study in two major tertiary hospitals in Saudi Arabia from March to December 2007. We enrolled all the patients on HD for two years or more, and excluded the patients who were transplant candidates, confused, or demented. The questionnaire was com-posed of 4 sections. The first 3 sections were concerned with demographic data, education levels, employ-ment, family size, number of children, and functionality status besides knowledge about cardiopulmonary resuscitation (CPR), mechanical ventilation, and ICU admission. The fourth section contained different sce-narios and questions on personal and preferences such as end of life decisions, medical interventions, CPR, ICU admission, and the decision maker in these events. A total of 100 patients (53% males, 67% Saudis, and 85% married) were enrolled in the study. The mean duration on dialysis was 6.0 years (± 4.1). More than 70% of the patients viewed themselves as above average in the religiosity score, and 44% disclosed a good life quality. More than 95% had little or no knowledge about cardiac resuscitation, intubation, and mechanical ventilation. The majority of the patients authorized their treating physician to decide for them about cardiac resuscitation in case they did not make advanced directives and only 22% believed that this decision should be made by their family members. If their physician believed their condition was hopeless, 77% preferred to stay at home. We conclude that the majority of our patients had limited awareness about cardiac resuscitation measures. The majority of the patients trust their physicians to decide about the futility of resuscitation. Patients were able to decide reasonably well when they are well informed.

This is part II of two series review of reading chest radiographs in the critically ill. Conventional chest radiography remains the cornerstone of day to day management of the critically ill occasionally supplemented by computed tomography or ultrasound for specific indications. In this second review we discuss radiographic findings of cardiopulmonary disorders common in the intensive care patient and suggest guidelines for interpretation based not only on imaging but also on the pathophysiology and clinical grounds.

Restless legs syndrome (RLS) is an extremely distressing problem experienced by patients on dialysis; the prevalence appears to be greater than in the general population, with a wide variation from 6.6% to 80%. The diagnosis of RLS is a clinical one, and its definition has been clarified and standardized by internationally recognized diagnostic criteria, published in 1995 by the International Restless Legs Syndrome Study Group (IRLSSG). This study was designed to find out the prevalence of RLS in Saudi patients with end-stage renal disease (ESRD) on maintenance dialysis. This is a cross sectional study carried out between May and Sept 2007 at two centers, King Abdulaziz Medical City-King Fahad National Guard Hospital (KAMC-KFNGH), Riyadh and King Faisal Specialist Hospital and Research Centre (KFHRC), Jeddah, Saudi Arabia. Data were gathered on 227 Saudi patients on chronic maintenance hemodialysis or chronic peritoneal dialysis. The prevalence of RLS was measured using IRLSSG′s RLS Questionnaire (RLSQ). Potential risk factors for RLS including other sleep disorders, underlying cause of chronic renal failure, duration on dialysis, dialysis shift, biochemical tests and demographic data were also evaluated. The overall prevalence of RLS was 50.22% including 53.7% males and 46.3% females. Their mean age was 55.7 ± 17.2 years and mean duration on dialysis 40.4 ± 37.8 months. Significant predictors of RLS were history of diabetes mellitus (DM), coffee intake, afternoon dialysis, gender and type of dialysis (P= 0.03, 0.01, < 0.001, 0.05 and 0.009 respectively). Patients with RLS were found to be at increased risk of having insomnia and excessive daytime sleepiness (EDS) (P= < 0.001 and 0.001, respectively). Our study suggests that RLS is a very common problem in dialysis population and was significantly associated with other sleep disorders, particularly insomnia, and EDS. Optimal care of dialysis patient should include particular attention to the diagnosis and management of sleep disorders

Bronchiolitis obliterans organizing pneumonia (BOOP) was first described in the early 1980s as a clinicopathologic syndrome characterized symptomatically by subacute or chronic respiratory illness and histopathologically by the presence of granulation tissue in the bronchiolar lumen, alveolar ducts and some alveoli, associated with a variable degree of interstitial and airspace infiltration by mononuclear cells and foamy macrophages. Persons of all ages can be affected. Dry cough and shortness of breath of 2 weeks to 2 months in duration usually characterizes BOOP. Symptoms persist despite antibiotic therapy. On imaging, air space consolidation can be indistinguishable from chronic eosinophilic pneumonia (CEP), interstitial pneumonitis (acute, nonspecific and usual interstitial pneumonitis, neoplasm, inflammation and infection). The definitive diagnosis is achieved by tissue biopsy. Patients with BOOP respond favorably to treatment with steroids.

Bronchiectasis is a chronic lung disease, defined pathologically as irreversible dilatation of the bronchi. The clinical course of the disease is chronic and progressive and in most cases, causes lung damage over many years. There is usually an initial event, which causes impairment of mucociliary clearance of the bronchial tree. The respiratory tract becomes colonized by bacteria that inhibit the ciliary function and promote further lung damage. The hallmark of bronchiectasis, is a chronic cough with mucopurulent or purulent sputum, lasting for months to years and may progress to chronic respiratory failure. Diagnosis of bronchiectasis is suspected on the basis of clinical manifestations. In order to confirm the diagnosis and underlying causes, appropriate investigations must be performed. In this comprehensive review, we discuss the etiology, pathogenesis, clinical presentation, appropriate investigations and management of bronchiectasis.

OBJECTIVE: To evaluate the impact of an extensive education campaign for physicians, in effecting positive changes, in their asthma prescription practice, in line with the ′Saudi protocol for diagnosis and management of asthma′. MATERIALS AND METHODS : An extensive campaign on asthma management for physicians in Saudi Arabia was conducted in 1995-1996, based on the ′Saudi protocol for asthma diagnosis and management′. During this campaign, one day courses-cum-workshops were held in 19 different cities, for over 2500 physicians (8% of all physicians in the kingdom). To evaluate the changes in asthma prescription, we retrospectively reviewed the charts of 98 asthmatic patients in 1994 and 100 patients in 1997, attending the outpatient department of two tertiary care hospitals, with over 500 beds, each in Riyadh and Jeddah. Data on demographic profile of the patients, Pulmonary function test and medications prescribed, were analysed and compared between the two groups. RESULTS: The mean age and severity of asthma was similar in both the groups.The prescription rate of inhaled steroids and inhaled beta-agonists increased significantly, with decrease in the use of oral beta-agonists, oral steroids, Theophylline, sodium cromoglycate and ketotifen. Conclusion: The use of inhaled steroids and inhaled beta agonists, considerably improved after the asthma education campaign for physicians in Saudi Arabia. Education campaign for physicians may be effective and could help in the improvement of clinical practice towards a specific disease.

Abstract Background Acute asthma attacks remain a frequent cause of emergency department (ED) visits and hospital admission. Many factors encourage patients to seek asthma treatment at the emergency department. These factors may be related to the patient himself or to a health system that hinders asthma control. The aim of this study was to identify the main factors that lead to the frequent admission of asthmatic patients to the ED. Methods A cross-sectional survey of all the patients who visited the emergency room with bronchial asthma attacks over a 9-month period was undertaken at two major academic hospitals. The following data were collected: demographic data, asthma control in the preceding month, where and by whom the patients were treated, whether the patient received education about asthma or its medication and the patients’ reasons for visiting the ED. Result Four hundred fifty (N = 450) patients were recruited, 39.1% of whom were males with a mean age of 42.3 ± 16.7. The mean duration of asthma was 155.90 ± 127.13 weeks. Approximately half of the patients did not receive any information about bronchial asthma as a disease, and 40.7% did not receive any education regarding how to use asthma medication. Asthma was not controlled or partially controlled in the majority (97.7%) of the patients preceding the admission to ED. The majority of the patients visited the ED to receive a bronchodilator by nebuliser (86.7%) and to obtain oxygen (75.1%). Moreover, 20.9% of the patients believed that the ED managed them faster than the clinic, and 21.1% claimed that their symptoms were severe enough that they could not wait for a clinic visit. No education about asthma and uncontrolled asthma are the major factors leading to frequent ED visits (three or more visits/year), p-value = 0.0145 and p-value = 0.0003, respectively. Asthma control also exhibited a significant relationship with inhaled corticosteroid ICS use (p-value =0.0401) and education about asthma (p-value =0.0117). Conclusion This study demonstrates that many avoidable risk factors lead to uncontrolled asthma and frequent ED visits.

Abstract Background Studies have shown that insomnia is a common sleep disorder among patients with end-stage renal disease (ESRD). This study aimed to assess the prevalence of insomnia in Saudi patients with ESRD who are on maintenance dialysis. Methods This was an observational cross-sectional study carried out over a period of five months in two hemodialysis centers in Saudi Arabia. To assess the prevalence of insomnia, we used the ICSD-2 definition. We also examined the association between insomnia and other sleep disorders, the underlying causes of renal failure, dialysis duration, dialysis shift, and other demographic data. Results Out of 227 enrolled patients, insomnia was reported by 60.8%. The mean patient age was 55.7 ± 17.2 years; 53.7% were male and 46.3% were female. Insomnia was significantly associated with female gender, afternoon hemodialysis, Restless Legs Syndrome, high risk for obstructive Sleep Apnea Syndrome and excessive daytime sleepiness (P-values: 0.05, 0.01, < 0.0001, < 0.0001, and < 0.0001, respectively). No significant association was found between insomnia and other variables, including BMI, smoking habits, underlying etiology of renal failure, dialysis duration, association with hemoglobin, ferritin, and phosphorus or dialysis adequacy as measured by the Kt/V index. Conclusion Insomnia is common in dialysis patients and was significantly associated with other sleep disorders. Greater attention needs to be given to the care of dialysis patients with regard to the diagnosis and management of insomnia and associated sleep disorders.

Abstract Introduction Hughes-Stovin syndrome is a very rare disease with fewer than 30 cases reported in the literature. The disease is thought to be a variant of Behcet's disease and is defined by the presence of pulmonary artery aneurysm in association with peripheral venous thrombosis. Case presentation A previously healthy 23-year-old Saudi woman presented with massive hemoptysis a day prior to her admission to our hospital. She had a six-month history of recurrent fever, cough, dyspnea, and recurrent oral ulceration. Contrast-enhanced computed tomography scan of her chest and pulmonary angiogram demonstrated a single right-lower lobe pulmonary artery aneurysm. She underwent thoracotomy and right lower lobe resection. Her postoperative course was complicated by deep vein thrombosis. She also developed headache and papilledema, while a magnetic resonance imaging of her brain suggested vasculitis. Based on these clinical presentations, she was diagnosed and treated with Hughes-Stovin syndrome. Conclusion The majority of cases of Hughes-Stovin syndrome are reported among men, with only two cases occurring in women. A case of Hughes-Stovin syndrome occurring in a woman is presented in this report. She was treated successfully with multimodality treatment that includes surgery, steroids and cytotoxic agents.

Background: A 9-month regimen of isoniazid can prevent active tuberculosis in persons with latent tuberculosis infection. However, the regimen has been associated with poor adherence rates and with toxic effects.Methods: In an open-label trial conducted in nine countries, we randomly assigned adults with latent tuberculosis infection to receive treatment with a 4-month regimen of rifampin or a 9-month regimen of isoniazid for the prevention of confirmed active tuberculosis within 28 months after randomization. Noninferiority and potential superiority were assessed. Secondary outcomes included clinically diagnosed active tuberculosis, adverse events of grades 3 to 5, and completion of the treatment regimen. Outcomes were adjudicated by independent review panels.Results: Among the 3443 patients in the rifampin group, confirmed active tuberculosis developed in 4 and clinically diagnosed active tuberculosis developed in 4 during 7732 person-years of follow-up, as compared with 4 and 5 patients, respectively, among 3416 patients in the isoniazid group during 7652 person-years of follow-up. The rate differences (rifampin minus isoniazid) were less than 0.01 cases per 100 person-years (95% confidence interval [CI], -0.14 to 0.16) for confirmed active tuberculosis and less than 0.01 cases per 100 person-years (95% CI, -0.23 to 0.22) for confirmed or clinically diagnosed tuberculosis. The upper boundaries of the 95% confidence interval for the rate differences of the confirmed cases and for the confirmed or clinically diagnosed cases of tuberculosis were less than the prespecified noninferiority margin of 0.75 percentage points in cumulative incidence; the rifampin regimen was not superior to the isoniazid regimen. The difference in the treatment-completion rates was 15.1 percentage points (95% CI, 12.7 to 17.4). The rate differences for adverse events of grade 3 to 5 occurring within 146 days (120% of the 4-month planned duration of the rifampin regimen) were -1.1 percentage points (95% CI, -1.9 to -0.4) for all events and -1.2 percentage points (95% CI, -1.7 to -0.7) for hepatotoxic events.Conclusions: The 4-month regimen of rifampin was not inferior to the 9-month regimen of isoniazid for the prevention of active tuberculosis and was associated with a higher rate of treatment completion and better safety. (Funded by the Canadian Institutes of Health Research and the Australian National Health and Medical Research Council; ClinicalTrials.gov number, NCT00931736 .). [ABSTRACT FROM AUTHOR]

Background and Aim: Hughes-Stovin syndrome (HSS) is a rare systemic vasculitis with widespread venous/arterial thrombosis and pulmonary vasculitis. Distinguishing between pulmonary embolism (PE) and in-situ thrombosis in the early stages of HSS is challenging. The aim of the study is to compare clinical, laboratory, and computed tomography pulmonary angiography (CTPA) characteristics in patients diagnosed with PE versus those with HSS., Methods: This retrospective study included 40 HSS patients with complete CTPA studies available, previously published by the HSS study group, and 50 patients diagnosed with PE from a single center. Demographics, clinical and laboratory findings, vascular thrombotic events, were compared between both groups. The CTPA findings were reviewed, with emphasis on the distribution, adherence to the mural wall, pulmonary infarction, ground glass opacification, and intra-alveolar hemorrhage. Pulmonary artery aneurysms (PAAs) in HSS were assessed and classified., Results: The mean age of HSS patients was 35 ± 12.3 years, in PE 58.4 ± 17 (p < 0.0001). Among PE 39(78 %) had co-morbidities, among HSS none. In contrast to PE, in HSS both major venous and arterial thrombotic events are seen.. Various patterns of PAAs were observed in the HSS group, which were entirely absent in PE. Parenchymal hemorrhage was also more frequent in HSS compared to PE (P < 0.001)., Conclusion: Major vascular thrombosis with arterial aneurysms formation are characteristic of HSS. PE typically appear loosely-adherent and mobile whereas "in-situ thrombosis" seen in HSS is tightly-adherent to the mural wall. Mural wall enhancement and PAAs are distinctive pulmonary findings in HSS. The latter findings have significant therapeutic ramifications., Competing Interests: Declaration of competing interest The authors declare no conflict of interest regarding this study., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)