Faculty Bibliography

Obstructive sleep apnea syndrome is a widely prevalent disorder, hallmarked by partial or total upper airway obstruction during sleep. These events fracture sleep integrity resulting in chronic partial sleep deprivation with destructive metabolic sequelae, the focus of this review.

BACKGROUND:The study's objective was to determine the diagnostic yield, morbidity, mortality, and therapeutic impact of open-lung biopsy (OLB) in mechanically ventilated, critically ill patients. MATERIAL/METHODS/METHODS:The study was conducted as a retrospective cohort study in multidisciplinary ICU in a tertiary level academic center and included all patients with respiratory failure and diffuse pulmonary infiltrates who underwent OLB between 1996-2004. Patient demographics, presenting symptoms, co-morbidities, APACHEII and SAPS II scores, and the diagnostic work-up preceding OLB were recorded. Pre- and post-biopsy PaO(2)/FiO(2) ratios, lung compliance, and PEEP were documented. The impact of histological diagnosis on the management was determined. Operative complications including bleeding, intraoperative hemodynamic instability, and persistent air leak were also reviewed. RESULTS:Fourteen patients were identified. The median ventilator time before OLB was 8.5 days. Nine patients were on inotropes and seven on renal replacement therapy at the time of biopsy. PaO(2)/FiO(2) ratio, lung compliance, and PEEP levels pre- and post-biopsy were not significantly different. Histological diagnoses were established in all 14 patients. Biopsy results led to the addition of a new therapy in 9 patients (64%) and the withdrawal of unnecessary therapy in 2 patients (14%). No major perioperative or intraoperative complications occurred. Six (43%) patients were discharged alive from the hospital. CONCLUSIONS:Open-lung biopsy in mechanically ventilated critically ill patients provides significant diagnostic information leading to change in the management of the majority of patients. The procedure is well tolerated and associated with an acceptable benefit-to-risk ratio.

OBJECTIVE:This review examines perspectives of human infection with avian influenza A H5N1 (AI H5N1), specifically focusing on the presentation, diagnosis, and management of those critically ill with AI H5N1. DATA SOURCE/METHODS:PubMed (1966-2006), PubMed "related articles," publications and Web sites of the World Health Organization and the Centers for Disease Control and Prevention, personal files, abstract proceedings, and reference lists. STUDY SELECTION/METHODS:We reviewed English-language publications pertaining to clinical presentation, diagnosis, and management of AI H5N1 and infection control expressly relating to the intensive care setting. DATA SYNTHESIS/RESULTS:The majority of reported patients with AI H5N1 are critically ill and require intensive care management. These patients progress rapidly to severe acute respiratory distress syndrome. Multiorgan failure occurs in a large proportion. Because of the nonspecific clinical, laboratory, and radiologic features, it is critical to seek a history of exposure to poultry or wild birds in suspected cases. Reverse transcription polymerase chain reaction performed on nasopharyngeal aspirate is the most reliable method for the laboratory diagnosis of AI H5N1. Treatment includes starting neuraminidase inhibitor oseltamivir as early as possible in addition to the standard supportive management. Aerosol generating procedures should be minimized to avoid nosocomial transmission. Strict infection control procedures are paramount to staff safety, although human-to-human transmission is rare as of this time. CONCLUSIONS:Many patients with AI H5N1 are critically ill either at presentation or shortly thereafter. Intensivists and intensive care units are therefore at the front line for this new cause of severe lung injury. Practitioners must be familiar with the nonspecific presentation of AI H5N1 and its diagnostic and therapeutic options. Although treating the infected patient with AI H5N1 is a priority, safeguarding healthcare workers and other patients must be considered of equal priority.

Annually, millions of Muslims embark on a religious pilgrimage called the "Hajj" to Mecca in Saudi Arabia. The mass migration during the Hajj is unparalleled in scale, and pilgrims face numerous health hazards. The extreme congestion of people and vehicles during this time amplifies health risks, such as those from infectious diseases, that vary each year. Since the Hajj is dictated by the lunar calendar, which is shorter than the Gregorian calendar, it presents public-health policy planners with a moving target, demanding constant preparedness. We review the communicable and non-communicable hazards that pilgrims face. With the rise in global travel, preventing disease transmission has become paramount to avoid the spread of infectious diseases, including SARS (severe acute respiratory syndrome), avian influenza, and haemorrhagic fever. We examine the response of clinicians, the Saudi Ministry of Health, and Hajj authorities to these unique problems, and list health recommendations for prospective pilgrims.

PURPOSE OF REVIEW/OBJECTIVE:Conducting large-scale clinical trials in the field of acute respiratory failure requires substantial collaboration. Teamwork is still in its infancy within the realm of clinical research. This review evaluates the need for and grassroots process of teamwork and considers the challenges facing teamwork in the specific context of conducting acute respiratory failure research today. RECENT FINDINGS/RESULTS:Acute respiratory failure research demands complex, interdependent tasks, dictating a teamwork approach. The team is comprised of a sponsor, a leader and members. The sponsor provides essential administrative support, the leader performs many of the functions of a traditional manager in addition to adopting three distinct roles of initiator, role model and coach, and members are selected not only on their technical expertise, but also on their problem-solving and interpersonal skills. SUMMARY/CONCLUSIONS:As large-scale (oftentimes international) multicenter trials are increasingly providing answers to our research questions, greater emphasis must be placed on team building within the clinical research environment. An urgent need for further work in this area is revealed. Critical care fellowships should integrate teamwork skills into the curriculum.

BACKGROUND:Attempted suicide by intentional drug overdose is an understudied subject in Saudi Arabia. Saudi Arabia is an Islamic country where suicide or attempted suicide is strictly prohibited. Despite the strong religious and constitutional sanctions against suicide, cases of intentional drug overdose occasionally occur. Our study represents the first attempt to better understand and characterize this sensitive topic. METHODS:Using a retrospective chart review of patients aged 12 years and over with a diagnosis of intentional drug overdose between 1997 and 1999, we studied the demographic characteristics, the risk factors, the most commonly used drugs, and the resulting morbidities and mortalities of study subjects. RESULTS:Most of the patients were young (mean age 22 years, SD 4.6, range 15 to 40 years), and most were Saudi nationals (n = 76; 96%). Eighty percent of the patients were women. The occurrence of intentional drug overdose peaked during the month of September (that is, 20% of total cases). Previous suicide attempts, family conflicts, and psychiatric disorders represented significant risk factors. Single-agent overdose occurred in 30% of the patients, and most of the drugs used were prescribed medications (53%). Acetaminophen represented the most common drug (30%). While some patients required prolonged hospital stay or admission to the intensive care unit, no mortalities occurred. CONCLUSIONS:Intentional drug overdose is a relatively uncommon reason for hospital admission in Saudi Arabia. This study identifies certain risk factors relevant to the Saudi community and raises awareness about intentional drug overdose.