Inhaled Nitric Oxide for Clinical Management of COVID-19: A Systematic Review and Meta-Analysis

Background: Severe COVID-19 is associated with hypoxemia and acute respiratory distress syndrome (ARDS), which may predispose multiorgan failure and death. Inhaled nitric oxide (iNO) is a clinical vasodilator used in the management of acute respiratory distress syndrome (ARDS). This study evaluated the response rate to iNO in patients with COVID-19-ARDS. Method: We searched Medline and Embase databases in May 2022, and data on the use of iNO in the treatment of ARDS in COVID-19 patients were synthesized from studies that satisfied predefined inclusion criteria. A systematic synthesis of data was performed followed by meta-analysis. We performed the funnel plot and leave-one-out sensitivity test on the included studies to assess publication bias and possible exaggerated effect size. We compared the effect size of the studies from the Unites States with those from other countries and performed meta-regression to assess the effect of age, year of publication, and concomitant vasodilator use on the effect size. Results: A total of 17 studies (including 712 COVID-19 patients) were included in this systematic review of which 8 studies (involving 265 COVID-19 patients) were subjected to meta-analysis. The overall response rate was 66% (95% CI, 47–84%) with significantly high between-studies heterogeneity (I2 = 94%, p < 0.001). The funnel plot showed publication bias, although the sensitivity test using leave-one-out analysis showed that removing any of the study does not remove the significance of the result. The response rate was higher in the Unites States, and meta-regression showed that age, year of publication, and use of concomitant vasodilators did not influence the response rate to iNO. Conclusion: iNO therapy is valuable in the treatment of hypoxemia in COVID-19 patients and may improve systemic oxygenation in patients with COVID-19-ARDS. Future studies should investigate the mechanism of the activity of iNO in COVID-19 patients to provide insight into the unexplored potential of iNO in general ARDS

A grey wolf-based method for mammographic mass classification

Breast cancer is one of the most prevalent cancer types with a high mortality rate in women worldwide. This devastating cancer still represents a worldwide public health concern in terms of high morbidity and mortality rates. The diagnosis of breast abnormalities is challenging due to different types of tissues and textural variations in intensity. Hence, developing an accurate computer-aided system (CAD) is very important to distinguish normal from abnormal tissues and define the abnormal tissues as benign or malignant. The present study aims to enhance the accuracy of CAD systems and to reduce its computational complexity. This paper proposes a method for extracting a set of statistical features based on curvelet and wavelet sub-bands. Then the binary grey wolf optimizer (BGWO) is used as a feature selection technique aiming to choose the best set of features giving high performance. Using public dataset, Digital Database for Screening Mammography (DDSM), different experiments have been performed with and without using the BGWO algorithm. The random forest classifier with 10-fold cross-validation is used to achieve the classification task to evaluate the selected set of features’ capability. The obtained results showed that when the BGWO algorithm is used as a feature selection technique, only 30.7% of the total features can be used to detect whether a mammogram image is normal or abnormal with ROC area reaching 1.0 when the fusion of both curvelet and wavelet features were used. In addition, in case of diagnosing the mammogram images as benign or malignant, the results showed that using BGWO algorithm as a feature selection technique, only 38.5% of the total features can be used to do so with high ROC area result at 0.871

Physicians’ attitudes, beliefs and barriers to a pulmonary rehabilitation for COPD patients in Saudi Arabia: a cross-sectional study

This study aimed to assess physicians’ attitudes toward delivering pulmonary rehabilitation (PR) to chronic obstructive pulmonary disease (COPD) patients and identify factors and barriers that might influence referral decisions. Between September 2021 and January 2022, a cross-sectional online survey was distributed to all physicians in Saudi Arabia. A total of 502 physicians completed the online survey, of which 62.0% (n = 312) were male. General physicians accounted for 51.2%, while internal-medicine specialists and pulmonologists accounted for 26.9% and 6.6%, respectively. Only 146 (29%) physicians had referred COPD patients to a PR program. The difference in referral rates between all specialties (p = 0.011) was statistically significant. Physicians with more years of experience were more likely to refer COPD patients to PR (p < 0.001). Moreover, a home-based PR program was preferred by 379 physicians (75.5%), and 448 (89.2%) perceived smoking cessation as an essential component of PR. Availability of PR centers (69%) was the most common barrier for not referring patients to PR. The overall referral rate was low among all physicians, owing to a lack of PR centers and trained staff. Home-based delivery was the preferred method of delivering PR, with smoking cessation as an essential component

Role of dysregulated prostanoids, nitric oxide and endothelin in cigarette smoke-and hypoxia-induced pulmonary vascular remodelling in COPDassociated pulmonary hypertension

Pulmonary hypertension (PH) due to chronic obstructive pulmonary disease (COPD) is classified as Group 3 PH, with no current proven targeted therapies. Studies suggest that cigarette smoke, the most risk factor for COPD can cause vascular remodelling and eventually PH as a result of dysfunction and proliferation of pulmonary artery smooth muscle cells (PASMCs) and pulmonary artery endothelial cells (PAECs). In addition, hypoxia is a known driver of pulmonary vascular remodelling in COPD, and it is also thought that the presence of hypoxia in patients with COPD may further exaggerate cigarette smoke-induced vascular remodelling; however, the underlying cause is not fully understood. Three main pathways (prostanoids, nitric oxide and endothelin) are currently used as a therapeutic target for the treatment of patients with different groups of PH. However, drugs targeting these three pathways are not approved for patients with COPD-associated PH due to lack of evidence. Thus, this review aims to shed light on the role of impaired prostanoids, nitric oxide and endothelin pathways in cigarette smoke- and hypoxia-induced pulmonary vascular remodelling and also discusses the potential of using these pathways as therapeutic target for patients with PH secondary to COPD

Psychological Resilience, Anxiety, and Well-Being of Health Care Providers During the COVID-19 Pandemic

Amani M AlQarni,1 Abdelaziz Elfaki,2 Moataza M Abdel Wahab,1 Yasser Aljehani,3 Auday A ALKhunaizi,4 Sharifah A Othman,5 Reem A AlShamlan2 1Family and Community Medicine Department, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 2Psychiatry Department, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 3Department of Surgery, King Fahd Hospital of the University, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia; 4Emergency Department, Qatif Central Hospital, Qatif, Saudi Arabia; 5Obstetrics and Gynaecology Department, King Fahd Hospital of the University, Dammam, Saudi ArabiaCorrespondence: Reem A AlShamlan; Amani M AlQarni, Tel +966536353448 ; +966591775751, Email [email protected]; [email protected]: On the frontlines of the pandemic, healthcare providers (HCPs) are overworked, anxious, and fearful. Yet, despite all the fear and anxiety, the facilitation of protective resilience and psychological well-being has become crucial to ensure that minimal intangible psychological losses are incurred due to the pandemic.Aim: The present study aimed to examine the psychological resiliency, state anxiety, trait anxiety, and psychological well-being of frontline HCPs during the COVID-19 and to determine the association among resiliency, state-trait anxiety, and psychological well-being and their links with demographic and workplace factors.Design and Settings: A cross-sectional study concerning frontline HCPs was conducted at two of the largest hospitals in the eastern province of Saudi Arabia.Results: A significant inverse correlation was determined between resilience and state anxiety (r=− 0.417, p< 0.05) and between resilience and trait anxiety (r=− 0.536, p< 0.05). Likewise, a positive intermediate correlation between resilience and the age of the individual (r=0.263, p< 0.05) and a weak positive correlation with years of experience (r=0.211, p< 0.05) were established. Also, the resilience score of volunteer workers (50.9) was lower than that of regular staff (66.8) (p=0.028).Conclusion: Resilience is a crucial factor affecting the training of individuals, which will further promote their work output and mental health capacity, thus improving their overall concept of survival in adversity.Keywords: psychological distress, anxiety, resilience, well-being, COVID-19 pandemic, health care provider

Knowledge and practice of using airway pressure release ventilation mode in ARDS patients: a survey of physicians

Background: Limited data is available on awareness and clinical management of the airway pressure release ventilation (APRV) mode of ventilation for acute respiratory distress syndrome (ARDS) patients among physicians who work at in adult critical areas. This study aimed to assess the knowledge and current practice of using APRV mode with ARDS patients and identify barriers to not using this mode of ventilation among physicians who work in adult critical areas in Saudi Arabia. Methods: Between November 2022 and April 2023, a cross-sectional online survey was disseminated to physicians who work in adult critical areas in Saudi Arabia. The characteristics of the respondents were analyzed using descriptive statistics. Percentages and frequencies were used to report categorical variables. Results: Overall, 498 physicians responded to the online survey. All responders (498, 100 %) reported that APRV is indicated in patients with ARDS, but 260 (52.2 %) did not know if there was an institutionally approved APRV protocol. Prone positioning was the highest recommended intervention by 164 (33.0 %) when a conventional MV failed to improve oxygenation in patients with ARDS. 136 (27.3 %) responders stated that the P-high should be set equal to the plateau pressure on a conventional ventilator while 198 (39.8 %) said that P-low should be 0 cmH2O. Almost half of (229, 46.0 %) responders stated that the T-high should be set between 4 and 6 s, while 286 (57.4 %) said that the T-low should be set at 0.4–0.8 s. The maximum allowed tidal volume during the release phase should be 4–6 ml/kg. Moreover, just over half (257, 51.6 %) believed that the maximum allowed P-high setting should be 35 cmH2O. One third of the responders (171, 34.3 %) stated that when weaning patients with ARDS while in APRV mode, the P-high should be reduced gradually to reach a target of 10 cmH2O. However, 284 (36.9 %) thought that the T-high should be gradually increased to reach a target of 10 s. Most responders (331, 66.5 %) felt that the criteria to switch the patient to CPAP would be to have an FiO2 ≤ 0.4, P-high ≤10 cm H2O, and T-high ≥10 s. Lack of training has been the most common barrier to not using APRV by 388 (77.9 %). Conclusion: There is a lack of consensus on the use of APRV mode, probably due to several barriers. While there were some agreements on the management of ventilation and oxygenation, there were variations in the selection of the initial setting of APRV. Education, training, and the presence of standardized protocols may help to provide better management

Inhaled therapies targeting prostacyclin pathway in pulmonary hypertension due to COPD: Systematic review

Background: Pulmonary hypertension due to chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) is classified as group 3 pulmonary hypertension. Inhaled treprostinil, a prostaglandin I2 analogue also known as prostacyclin, has recently been approved as a first drug for patients with pulmonary hypertension secondary to ILD. However, due to a lack of evidence, no therapies are currently approved for those with COPD-associated pulmonary hypertension. Thus, this systematic review aims to summarise the current evidence to assess the impact of inhaled prostaglandin I2 analogue use on the pulmonary hemodynamics, exercise function, lung function, and gas exchange in patients with pulmonary hypertension due to COPD.We systematically searched the electronic databases of Medline, Embase, Scopus and Cochrane from inception to 1 February 2023. Studies of adult patients with a confirmed diagnosis of COPD-associated pulmonary hypertension who received inhaled drugs targeting the prostacyclin pathway were included in the systematic review. Case reports, systematic reviews, conference abstracts with no full text, non-full-text articles, non-English manuscripts and book chapters were excluded from this systematic review. A risk-of-bias assessment was carried out for the studies included in this review, using two different Cochrane risk-of-bias tools for randomised and non-randomised clinical trials.Results: A total of four studies met our inclusion criteria and were included in this systematic review.The results of one prospective clinical trial showed an improvement in the pulmonary hemodynamics (e.g., cardiac index, cardiac output and mean pulmonary artery pressure) in response to inhaled prostacyclin use in patients with pulmonary hypertension secondary to COPD. However, the severity of dyspnoea, lung function, exercise capacity and gas exchange were not affected when inhaled prostacyclin was used for patients with COPD-related pulmonary hypertension. Deleted: hemodynamic index 55 Deleted: hemodynamic index Conclusion: This systematic review demonstrated that although inhaled prostacyclin does not seem to improve COPD-related outcomes (e.g., lung function and exercise capacity), short-term use of inhaled prostacyclin has the potential to reduce mean pulmonary artery pressure and pulmonary vascular resistance without impairing ventilation-perfusion mismatch. Further studies with larger sample sizes are warranted

Gender Differences in Prevalence of Sleepy Driving Among Young Drivers in Saudi Arabia

Yousef D Alqurashi,1 Abdullah S Alqarni,1 Faisal Maher Albukhamsin,1 Abdullah Abdulaziz Alfaris,1 Bader Ibrahim Alhassan,1 Waleed Khalid Ghazwani,1 Abdulaziz Abdulrahman Altammar,1 Mutlaq Eid Aleid,1 Hayfa Almutary,2 Abdulelah M Aldhahir,3 Saleh A Alessy,4 Rayyan Almusally,5 Abir Alsaid,5 Mahmoud Ibrahim Mahmoud,5 Hatem Othman Qutub,5 Tunny Sebastian,6 Suliman Alghnam,7 Michael I Polkey8 1Respiratory Care Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 2Medical Surgical Nursing Department, King Abdulaziz University, Jeddah, Saudi Arabia; 3Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia; 4Department of Public Health, College of Health Sciences, Saudi Electronic University, Jeddah, Saudi Arabia; 5Internal Medicine Department, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Khobar, Saudi Arabia; 6Clinical Nutrition Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 7Population Health Section-King Abdullah International Medical Research Center (KAIMRC), King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia; 8Royal Brompton Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UKCorrespondence: Yousef D Alqurashi, Respiratory Care Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, 34221, Saudi Arabia, Email [email protected]: Sleepy driving is associated with Motor Vehicles Accidents (MVAs). In Saudi Arabia, previous studies have addressed this association among men only. Therefore, the aim of this study was to compare the prevalence of sleepy driving and associated factors between genders.Methods: In a cross-sectional study design, we offered a self-administered online questionnaire to 3272 participants from different regions of Saudi Arabia. The questionnaire included 46 questions covering sociodemographics, driving habits, sleeping habits, Epworth Sleepiness Scale, and Berlin questionnaire to assess the risk of sleep apnea. Univariable and multivariable logistic regression analyses were used to determine the significant factors associated with self-reported sleepy driving, defined as operating a motor vehicle while feeling sleepy in the preceding six months.Results: Of the 3272 invitees, 2958 (90%) completed the questionnaire, of which 1414 (48%) were women. The prevalence of sleepy driving in the preceding six months was 42% (men: 50% and women 32%, p< 0.001). Specifically, participants reported the following: 12% had had to stop their vehicle due to sleepiness (men: 16.2% and women 7%, p< 0.001), 12.4% reported near-miss accidents (men: 16.2% and women: 8.2%, p< 0.001) and 4.2% reported an accident due to sleepiness (men: 4.3% and women: 4%, p=0.645). In multivariable analysis, being male, younger age, use of any type of medications, shift working, working more than 12 hours per day, driving duration of 3– 5 hours per day, driving experience of more than 2 years, excessive daytime sleepiness and risk of having obstructive sleep apnea were all associated with increased likelihood of falling asleep while driving in the preceding 6 months.Conclusion: Sleepy driving and MVA are prevalent in both gender but was higher in men. Future public health initiatives should particularly focus on men, since men reported a greater likelihood of both sleep-related MVA and “near miss” events.Keywords: sleepiness, driving, obstructive sleep apnea, OSA, gender difference

Physicians&rsquo; Knowledge of Abdominal Compartment Syndrome and Intra-Abdominal Hypertension in Saudi Arabia: An Online Cross-Sectional Survey Study

Rayan Qutob,1,2 Alanoud Hassan A Alkhannani,1 Turki Yazeed Alassaf,1 Saad Othman Alhokail,1 Ghassan Abdullah Bagazi,1 Abdulmalak Abdullah Alsaleh,1 Mashael kamel alqarni,1 Yousef Alammari,1 Khalid Al Harbi,1 Alyaa Elhazmi,3 Abdullah Ibrahim Bukhari,1 Abdullah Alaryni,1 Abdullah Alghamdi,1 Osamah A Hakami1 1Faculty of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia; 2Adult Critical Care Department, Dr. Sulaiman Al-Habib Medical Group, Riyadh, Saudi Arabia; 3College of Medicine, AlFaisal University, Riyadh, Saudi ArabiaCorrespondence: Alanoud Hassan A Alkhannani, Faculty of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia, Tel +966 545436837, Email [email protected]: To determine physicians’ knowledge of abdominal compartment syndrome and intra-abdominal hypertension in Saudi Arabia.Methods: A cross-sectional online survey study was conducted on physicians in Saudi Arabia between March and August 2022. A previously developed questionnaire was adapted and used in this study. The survey instrument investigated the knowledge and management of intra-abdominal hypertension and abdominal compartment syndrome among physicians. Logistic regression was used to identify predictors of being knowledgeable about abdominal compartment syndrome and intra-abdominal hypertension.Results: A total of 266 physicians participated in this study. Around one-fifth (21.8%) the study participants were ICU physicians and 25.0% reported that they practice internal medicine. Intra-abdominal hypertension (IAH) and the impact of increased intra-abdominal pressure (IAP) on organ function were terms that the majority of research participants (70.3%) reported they were familiar with. A similar percentage (73.7%) reported that they are familiar with abdominal compartment syndrome (ACS). Around 43.0% of the study participants reported that they do not know how to measure IAP. The most frequently reported (13.5%) intervention in the treatment of IAH and ACS was the use of inotropes or vasopressors. The study participants showed a weak level of knowledge of ACS and IAH with a median score of 3.00 (IQR: 5.00– 2.00), which represents 27.3% of the maximum attainable score. Physicians working at hospitals with 20– 50 ICU beds were 41.0% (odds ratio: 0.59 (CI: 0.37– 0.96)) less likely to be knowledgeable about intra-abdominal hypertension and abdominal compartment syndrome (p≤ 0.05).Conclusion: Physicians demonstrated a low level of IAP and ACS knowledge. To increase the safety of medical practices and enhance clinical outcomes for patients, awareness should be raised about the proper diagnosis and management of IAP and ACS. Future research should focus on developing effective educational strategies to improve physicians’ understanding of IAP and ACS.Keywords: abdominal compartment syndrome, intra-abdominal hypertension, intra-abdominal pressure, knowledge, physicians, Saudi Arabi