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Respiratory disorders in the Middle East: A review

  • SSMC-Mayo clinic JV

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The spectrum of pulmonary pathology in the Middle East is as versatile as its civilizations and cultures. In this review, we outline the key challenges confronting pulmonologists in the Middle East. We shed light on the diverse conditions commonly encountered in the region, from the centuries-old illnesses of tuberculosis, to contemporary problems such as lung complications from chemical warfare. We specifically highlighted unique aspects related to respiratory illnesses in the Middle East, for example, climate factors in the desert region, cultural habits, for example, water-pipe smoking and disorders unique to the region, such as Behçet's disease. Pulmonologists are also faced with the consequences of modernization, including large immigrant population and associated social and health issues, rising incidence of obesity and sleep apnoea, and drug-resistant tuberculosis. Tackling these health issues will require an integrated approach involving public health, primary care as well as specialist pulmonology input, taking into consideration the unique cultural and environmental factors to ensure effective management and compliance to medical care.
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Respiratory disorders in the Middle East: A reviewresp_1988 755..766
1Division of Internal Medicine, Sheikh Khalifa Medical City,2Division of Respirology, Department of Medicine,
Sheikh Khalifa Medical City,3Department of Medicine, Sheikh Khalifa Medical City,4Sheikh Khalifa Medical
City, Abu Dhabi,5Division of Pulmonology and Allergy, Rashid Hospital, Dubai and 6Zulekha Hospital, Sharjah,
UAE,and 7Division of Pulmonology, King Abdulaziz Medical City, Riyadh, KSA
The spectrum of pulmonary pathology in the Middle
East is as versatile as its civilizations and cultures. In
this review, we outline the key challenges confronting
pulmonologists in the Middle East. We shed light on
the diverse conditions commonly encountered in the
region, from the centuries-old illnesses of tuberculosis,
to contemporary problems such as lung complications
from chemical warfare. We specifically highlighted
unique aspects related to respiratory illnesses in the
Middle East, for example, climate factors in the desert
region, cultural habits, for example, water-pipe
smoking and disorders unique to the region, such as
Behçet’s disease. Pulmonologists are also faced with
the consequences of modernization, including large
immigrant population and associated social and health
issues, rising incidence of obesity and sleep apnoea,
and drug-resistant tuberculosis. Tackling these health
issues will require an integrated approach involving
public health, primary care as well as specialist
pulmonology input, taking into consideration
the unique cultural and environmental factors to
ensure effective management and compliance to
medical care.
Key words: bronchial disease, Middle East, pleural
disease, respiratory tract infection, respiratory tract
The Middle East, also known as Mideast or Near East,
is a term initially coined by a British officer, General
Sir T.E. Gordon, in 1900.1It has a loose political and
geographic definition. It is grossly referred to the
region stretching from the Eastern Mediterranean to
the western side of the Indian subcontinent, and from
Turkey in the North to the Arabian Peninsula in the
South. It has been the cradle of many famous civiliza-
tions and well-known religions.
The Middle East had been experiencing a variety
of human interactions since antiquity. These include
human migration and settlements, inter-marriage
between civilizations, frequent wars bringing devas-
tation and newly established industrial activities with
all its possible detrimental consequences.
The wealth of pulmonary pathologies encountered
in the Middle East probably surpasses all other
regions of the world. While older lung diseases, such
as pulmonary tuberculosis, still have a firm foothold
there; health-care practitioners are encountering
more and more ‘newer’ pathologies such as chronic
obstructive lung diseases secondary to inhaled
tobacco or other respiratory hazards. This review is
comprehensive but by no mean exhaustive.
The Authors: Dr Abdulkarim Waness holds the position of
SKMC Research Center Director and his clinical research inter-
ests include lipid disorders, infectious pathologies, lung and car-
diovascular diseases. Dr Yaser Abu El-Sameed is a Consultant of
Respirology at the Sheikh Khalifa Medical City with specialized
training and clinical interest in Interventional Pulmonology,
including benign and malignant airway and pleural disorders. Dr
Mahboub is an Affiliated Professor of Medicine and Chest
Disease at the University of Sharjah Faculty of Medicine, in
Sharjah, UAE and Head of Respiratory and Allergy Services, at
the Dubai Health Authority, Dubai, UAE. Dr Mohammed Noshi is
Head of the Department of Medicine, Sheikh Khalifa Medical City,
Abu Dhabi, UAE with special clinical and research interest in
respiratory diseases, allergy, asthma and sleep medicine. Dr
Hamdan Al-Jahdali is Head of the Division of Pulmonology, King
Abdulaziz Medical City, Riyadh, KSA with clinical and research
interest in allergy, asthma, sleep medicine and bronchology. Dr
Mayank Vats is a Consultant Pulmonologist, Intensivist and Sleep
Physician at Zulekha Hospital, Sharjah, UAE with active clinical
and research interest in asthma, sleep medicine and interven-
tional bronchology. Professor Atul C. Mehta is a Chief Medical
Officer at the Sheikh Khalifa Medical City, Abu Dhabi, UAE and a
Staff Physician at the Respiratory Institute, Cleveland Clinic,
Cleveland, Ohio, USA. He is also the Editor-in-Chief of the
Journal of Bronchology and Interventional Pulmonology. His
main areas of interests are interventional pulmonology and lung
Correspondence: Atul C. Mehta, Sheikh Khalifa Medical City,
PO Box 51900, Abu Dhabi, UAE. Email:
Received 16 September 2010; invited to revise 13 January
2011; revised 22 March 2011; accepted 27 April 2011 (Associate
Editor: Y.C. Gary Lee).
© 2011 The Authors
Respirology © 2011 Asian Pacific Society of Respirology
Respirology (2011) 16, 755–766
doi: 10.1111/j.1440-1843.2011.01988.x
Documenting human lung pathology throughout
ancient history is challenging. The Middle East, with
its rich and unique civilizations (e.g. the old Egyptian
civilization), has kept not only old manuscripts but
also archaic human corpses and mummies carrying
the stigmata of pulmonary pathologies. Recent
studies employing PCR on Egyptian mummies
provided evidence of pulmonary tuberculosis that
plagued this region for thousands of years.2Zimmer-
man speculated that Mycobacterium tuberculosis
evolved from Mycobacterium bovis 5000 years BC at
the Nile Valley during cattle domestication process.3
Lord Carnarvon, a British sponsor of archaeology in
Egypt, died shortly after attending King Tutankhamun
tomb’s opening in 1922. This well-publicized ‘King
Tut Curse’ or Mummy’s Curse’ can potentially be
explained by recent findings of Aspergillus niger and
Aspergillus flavus in some ancient mummies, which
can cause allergic bronchopulmonary aspergillosis
and pulmonary haemorrhage.4It remains unclear
if these mummies were infested by these moulds
post-mortem, or before death.
During the middle ages, the Middle East had a
flourishing Islamic medical renaissance. Many great
physicians left their valuable contributions and
lasting impressions on modern medicine. A classic
example is Ibn-Sina (c. 980–1037)—known as Avi-
cenna in Latin—who is considered the father of
modern medicine. He left multiple treaties and books
such as ‘The Canon in Medicine’ and laid down the
foundations of experimental medicine, clinical trials
and risk factor analysis. He hypothesized the exist-
ence of microorganisms, asserted that pulmonary
tuberculosis was contagious, and introduced quaran-
tine and stressed the importance of hygiene in patient
care to limit the spread of infectious diseases.5
Throughout its history, the Middle East populations
have suffered from a variety of lung conditions related
to weather conditions, traditional lifestyle or genetic
makeup. More contemporary pulmonary pathologies
are also present nowadays due to change in diets and
lifestyles, human migration, rapid industrialization
and deliberate use of harmful materials such as
uranium during wars.
We highlight the wide spectrum of lung diseases
relevant to the Middle East under several major
categories: environmental factors, infections,
genetic-idiopathic diseases, sleep disorders, lung
malignancies, pleural diseases and miscellaneous
respiratory conditions.
Environmental causes
A plethora of environmental factors contribute to
an ever-increasing list of pulmonary diseases in the
Middle East.
Climate factors
The Middle East has large areas covered by desert.
In summer, it is hot and can be very humid, whereas
in winter, temperature can drop significantly. These
weather variations can exacerbate chronic lung dis-
eases in susceptible individuals especially asthmatics.
The asthma prevalence in this part of the world has
not been described in details, but is believed to be
high. A recent study in the United Arab Emirates of
children between the ages of 6 and 19 years showed a
prevalence of 13%.6Asthma is well-known for its per-
sistent morbidity, school absenteeism and high thera-
peutic cost.7
In the Middle East, many sensitizing aeroallergens
from the desert can worsen asthma.8,9 Low parental
education, low birth weight/prematurity, family
history of asthma, cigarette smoking and the expo-
sure to indoor or outdoor allergens such as house dust
mites and pollen are all known contributing factors in
this region.10,11 Access to adequate asthma care varies
from one country to another and does not guarantee
good outcome.12
Sudden heavy exposure to dust and sand storm
may precipitate pulmonary alveolar proteinosis and
Social factors
The prevalence of tobacco smoking is high in the
Middle East and COPD is common.15 Al Zaabi A et al.
conducted a cross-sectional survey in a random
sample of 520 individuals (aged 40–80 years) in Abu
Dhabi, and revealed a prevalence of COPD at 3.7%
(95% CI: 2.0–5.3).16 The need for preventive education
is pressing.17
Unique to this region is smoking via the water-pipe,
also known as the hubbly-bubly or narguile.18 Water-
pipe use is increasing globally, particularly in the
Eastern Mediterranean region, where misperceptions
regarding the safety and health risks as well as tradi-
tional values often lead to water-pipe use in women
and children.19 Water-pipe smoke contains harmful
constituents and there is preliminary evidence linking
water-pipe smoking to a variety of life-threatening
conditions, including pulmonary disease, coronary
heart disease and pregnancy-related complications.20
Incense burning is another prevalent social habit
in the Middle East. It is documented that inhalation
of its fumes can trigger an asthma attack.21 In one
study, local inhaled exposures such as water-pipe or
bakhour use (incense burning) was associated with
the risk of COPD.16
Occupational exposure
Many agricultural and industrial agents contribute to
pulmonary disease in the Middle East. Textile workers
can develop byssinosis from inhalation of fine cotton
fibres.22 Psittacosis, also known as ornithosis or parrot
fever, can be contracted by the inhalation of dried
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Respirology (2011) 16, 755–766
excreta of infected birds with Chlamydia psittaci.23
Q-fever pneumonia caused by Coxiella burnetii,from
exposure to sheep, goats or cattle, is endemic to some
areas in the Middle East.24 Many other forms of pneu-
moconiosis from industrial exposure are sometimes
diagnosed in the region, and include silicosis,25 coal
mining,26,27 asbestos lung diseases,28 lignite inhala-
tion,29 radon gas exposure,30 working with tin metal31
or with beryllium.32
Modern industrialization brought more air
pollutants. Their impact on the respiratory health of
Middle Easterners has been detrimental.33 Factors
such second-hand smoking34,35 and fuel fumes36 are
on the rise.
Exposure to warfare
The Middle East if frequently plagued by wars and
high-tech chemical ammunitions used nowadays can
cause immediate lung injuries and potential long-
term pathologies. It was alleged that in the 1980s
chemical weapon was used in the Iran–Iraq war.
Mustard gas, for example, can cause bronchiolitis and
progressive pulmonary interstitial fibrosis.37 After the
Gulf war of 1991, the terms of ‘Persian Gulf Syndrome
emerged. It is speculated that inhaled fine desert
dust combined with released chemicals (dubbed
dirty dust) caused ‘desert-storm pneumonitis’.38 Some
authors speculate that the symptoms were associated
with inhalation of depleted uranium dust; more than
350 metric ton of this toxic material was used during
the 1991 Gulf war alone.39 It is unknown if long-term
exposure to depleted uranium can cause lung malig-
nancy, although studies done on German uranium
miners have shown a risk.40
Pulmonary infections
Mycobacterial infections
Mycobacterium tuberculosis has a good foothold in
the Middle East since antiquity. The emergence of
multi-drug-resistant (MDR) strains is compounding
this major health problem.41 The WHO reports an
alarming rise in the incidence of MDR tuberculosis
(TB) in Middle East. MDR TB accounts for 0.9–5.4% of
new TB cases in the region and 8.3–62.5% of patients
previously treated with TB had MDR isolates.42 The
main reasons for the rising drug resistance of TB in
the Middle East include:
Non-compliance: A considerable number of patients
stop their treatment prematurely.43 It is reported that
drug resistance is twice higher in patients who have
previously received anti-tuberculous therapy.44 The
lack of direct observed therapy in many Middle
Eastern countries also contributes to the emergence of
Immigrants: A large number of people migrate to
the Middle East usually for financial and religious
ones. Many come from regions with endemic prob-
lems of MDR TB, such as south east Asia, the Indian
subcontinent, the former Soviet Union and East
Religious trips: Hajj is the yearly Muslim pilgrimage
to Mecca. More than two million individuals flock
to this city. Overcrowding and unsanitary practices
promote M. tuberculosis infection.47 Alzeer et al.
reported that pulmonary TB was the commonest
cause of pneumonia requiring hospitalization during
Hajj.48 Radiographical presentations of pulmonary TB
can widely vary from normal findings, to Ghon’s
complex, to lung cavitation or miliary picture (Fig. 1).
Non-tuberculous mycobacterial lung infections, for
example by Mycobacterium kansasii49 and Myco-
bacterium abscessus,50 are occasionally observed in
the Middle East, especially in immunocompromised
patients or in cystic fibrosis patients.
Bacterial infection
Hospitalization rate for community-acquired pneu-
monia (CAP) has increased over the years in the
Middle East; in one study the commonest isolated
microorganisms from sputum cultures were Haemo-
philus influenzae (18.6%) and Streptococcus pneumo-
nia (10%). The overall mortality rate for CAP was 13%.
Pseudomonas aeruginosa was the most common
pathogen (50% of cases) causing hospital-acquired
pneumonia with a higher mortality rate of 24%.51
The incidence of ventilator-associated pneumonia
from a large ICU in Turkey was 22.6/1000 ventilator
days. The most frequently isolated pathogens were
Acinetobacter species: 90% of which were resistant
to ceftazidime, 64% resistant to imipenem and
80% resistant to ciprofloxacin. Methicillin-resistant
Staphylococcus aureus (MRSA) and P. aeruginosa
were also common in ventilator-associated pneu-
monia, with 59% of P. aeruginosa isolates being resis-
tant to ceftazidime, 32% to imipenem and 62% to
Figure 1 CT scan showing diffuse involvement of lung
in miliary tuberculosis.
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Like other parts of the world, MRSA is prevalent in
the Middle East hospitals causing severe morbidity
and mortality. Savas et al. reported that MRSA causes
approximately one-third of all nosocomial pneumo-
nia in a University hospital in Turkey.53
Brucellosis infection is common in the Middle East,
resulting from the ingestion of unpasteurized dairy
products or occupational exposure due to close con-
tacts with animals. Lung infection in brucellosis
occurs either by inhalation of infected aerosols (e.g.
which arises in slaughter house) or by bacteremic
spread as a part of the systemic infection. CXR usually
reveals non-specific patchy pneumonic infiltrates
with hilar and para-tracheal adenopathy. Diagnosis
depends upon a compatible travel and/or occupa-
tional history and is often supported by a serum
agglutination titre of 1/160 and confirmed by isola-
tion of brucella from body fluids. High consumption
of dairy products and non-vegeterian dietary pattern
are risk factors, and brucellosis should always be con-
sidered in patients with the forementioned clinic-
radiological presentation.54–56
Pulmonary nocardiosis is another respiratory infec-
tion encountered in the region, usually associated
with chronic pulmonary lung disease and corticoster-
oid use.57
Atypical organisms
Atypical organisms such as Chlamydia pneumoniae,
Mycoplasma pneumoniae and Legionella pneumo-
phila are prevalent in the Middle East and have a sig-
nificant role in the aetiology of CAP.58 Al-Ali et al.ina
study from Jordan, reported that C. pneumoniae and
My. pneumoniae were the leading pathogens of pneu-
monia in children (incidences 14% and 6% respec-
tively). In adults, C. pneumoniae (23% of all isolates)
was only second to S. pneumoniae in incidences while
My. pneumoniae was found in 9% and L. pneumophila
in 6% of cases.59
Viral infections
Viral pneumonias are common in the Mideast. In
an Iranian study the isolation rates Parainfluenza-1,
2 and 3 were 6.4%, 6.4% and 15.8% respectively. Other
viruses causing pneumonia were RSV (12.9%),
Influenza-A (7.4%) and B (3.5%) and adenovirus
(5.9%).60 Compliance with influenza vaccination
varies from one community to another.61 Varicella
pneumonia can be seen mostly in young patients and
can be severe requiring ventilatory support.62 More
recently, avian influenza has become endemic in some
parts of the Middle East, especially Egypt and Tur-
key.63,64 In March 2010, the World Health Organization
reported limited data about H1N1 Flu (Swine Flu) pan-
demic in North Africa and Western Asia. It was esti-
mated that this infection continue to circulate with an
increasing trend of respiratory diseases activity.65
The HIV has a low prevalence in the Middle East.66
A surveillance study by UNAIDS carried out in
Middle East and North Africa revealed an estimated
68 000 (41 000–220 000) people had acquired HIV in
2006, bringing to 460 000 (270 000–760 000) the total
number of people living with the virus in the region,
and AIDS killed approximately 36 000 (20 000–60 000)
people a year. Most reported HIV infections have been
in men, but the proportion of infected women is
increasing.67 Inadequate HIV surveillance in many
countries of this region makes it difficult to discern
the patterns and trends of their diverse epidemics—
especially among most-at-risk groups such as inject-
ing drug users and sex workers. Recently, HIV
surveillance programmes have been implemented in
some countries to stem the spread of this disease with
promising success.68 Effective HIV prevention pro-
grammes that target most-at-risk populations can
help prevent wider and more serious HIV epidemics
in the Middle East and North Africa. Patients with
AIDS or having other immunocompromising condi-
tions, such as post-organ transplantation, are prone
to many complications including pulmonary MDR
TB,69 disseminated herpes simplex virus infection and
cytomegalovirus pneumonitis.
Fungal infections
A variety of fungi affecting the lungs are often
encountered in the Middle East, especially in immu-
nosuppressed patients. Other risk factors include
broad-spectrum antibiotic use, ICU admission, total
parenteral nutrition and surgical instrumentations.
Since the time of King Tut, Aspergillus species have
been an important cause of severe cavitary lung dis-
ease.70 Many Candida species find fertile ground
in Middle Eastern medical facilities. Invasive candi-
demia is common.71 Mucormycosis, also known as
zygomycosis, can affect the respiratory system and
cause tremendous devastation.72,73 Pneumocystis
jiroveci (previously known as Pneumocystis carinii)is
another unicellular fungus that causes severe pneu-
monia.74 Sporadic cases of pulmonary histoplasmo-
sis,75 lung coccidioidomycosis76 and other yeast-like
organisms have occasionally been diagnosed in the
Middle East.77
Parasitic infections
Farming, herding and unsanitary hygienic practices
contribute to endemic parasitic infections in the
Middle East. Several types of parasitic infestations
with lung involvement known to occur in the Middle
East are described below.
Echinococcosis is considered an endemic zoonosis
in areas of the Middle East such as Egypt and Saudi
Arabia. Humans are accidental hosts to this parasitic
infestation; hydatiform cysts can grow in many
organs, including lungs, to monstrous sizes.78 Echino-
coccus granulosus was present in 5% of captured
street dogs in Egypt.79 Fahim and Al Salamah
described 117 patients (mean age: 40.9 20.7 and
male : female ratio 1.7:1) with Echinococcosis
in an endemic area of central Saudi Arabia.80 Right
upper quadrant pain and cough were the most
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common symptoms. Fourteen patients had intra-
bronchial rupture confirmed during bronchoscopy.
Antihelmenthic medications were given in addition to
the surgical treatment.81 Endocystectomy was com-
monly employed, but post-operative bronchopleural
fistula developed in three patients, one of whom
required surgical closure.
Schistosomiasis, also called bilharziosis or snail
fever, is endemic among rice farmers in the Nile Val-
ley.82 In early human infestation and after skin pen-
etration, the schistosomulum migrates to the lungs
through the pulmonary circulation. Schistosomiasis
is endemic in Egypt and Sudan. The prevalence of
infection with Schistosoma mansoni and Schistosoma
haematobium, or both, in 6122 children in the former
White Nile Province of Sudan was 10.1%, 21.4% and
4.5% respectively.83 In that study, the disease peaked
in those aged 10–19 years, both in men and women.
El-Khoby et al. detailed the epidemiology of schisto-
somiasis in Egypt and identified several risk factors
of the infestation: male gender, age <21 years, living
in smaller communities, exposures to canal water; a
history of schistosomiasis and history of blood in the
stool or urine.82 Pulmonary hypertension complicates
schistosomiasis in 18.5% of patients in one report.84
Ascaris lumbricoides is a parasitic roundworm seen
mostly in children with poor hygiene. It is acquired by
ingesting food contaminated with the parasite eggs.
This worm travels through the lungs but yields mostly
gastrointestinal symptoms. Ascaris may resemble
CAP in some patients85 or precipitate pulmonary
oedema in others.86
Leishmaniasis is also common in the Middle East.
It transmitted by sand-fly bites. Most cases are
cutaneous, cases of laryngeal leishmaniasis in both
immune-compromised and immune-competent
hosts have been documented.87
Genetic-idiopathic conditions
The Middle East has had one of the highest consan-
guinity rates in the world.88 Conditions such as sickle
cell disease (SCD), thalassaemias and birth defects
are prevalent. Some of these conditions can have a
significant impact on lung health.
Sickle cell disease
Sickle cell disease is relatively common in affected
racial groups from the Middle East, west and central
Africa, Greece, Turkey and India with an incidence of
~1:200 births.89 Lung involvement with homozygous
SCD is manifested in two major forms: the acute
chest syndrome and sickle cell chronic lung disease.90
Al-Suleiman et al. reported that 79% of their hospital-
ized patients with SCD subsequently developed acute
chest syndrome.91 Acute chest syndrome is character-
ized by the triad of chest pain, fever and appearance
of a new infiltrate (often first at the bases and then
involving whole lungs) on the chest radiograph. Chest
pain typically starts with bone pain in the thoracic
cage and often accompanied by pleurisy, tachycardia
and tacypnoea.92 SCD patients are also at high risk of
recurrent infections/pneumonia, pulmonary infarcts
and pulmonary embolism during pregnancy.93 Treat-
ment consists of antibiotic coverage, pain manage-
ment, maintaining adequate oxygenation, diluting
Haemoglobin S by transfusion of packed red cells and
exchange transfusion and respiratory support when
Sickle cell heterozygote are at risk of sickle cell crisis
after exposure to hypoxic conditions (unpressurized
aircrafts and under anaesthesia) with resultant
pulmonary and other organ infarction. This risk of
hypoxia is very much relevant for the Middle East
considering the huge numbers of immigrant popula-
tion who frequently travel by air.
Chronic lung disease associated with SCD, on the
other hand, manifests as interstitial abnormalities on
CXR or impaired pulmonary function testing. Both
restrictive and obstructive pattern have been encoun-
tered.94 In its most severe form, SCD can manifest
itself in the form of pulmonary hypertension (Fig. 2).
Bahcet’s syndrome
Bahcet’s syndrome is prevalent in the Middle East.
Turkey, in particular, has one of the world’s highest
rates of Behcet’s disease, which affects an estimated
42 patients per 10 000 people in Istanbul.95 It
has multiple clinical presentations including oral
aphthae, genital ulcers, and central nervous system,
gastrointestinal and pulmonary involvement. The
latter was observed to be more prevalent in men.96
Pulmonary manifestations include pulmonary artery
aneurysm, arterial and venous thrombosis, recurrent
Figure 2 Grossly enlarged pulmonary arteries in a case
of severe sickle cell disease with severe pulmonary artery
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pulmonary infarction with haemoptysis, recurrent
pneumonia, broncholitis obliterans organizing pneu-
monia and pleurisy.97
Cystic fibrosis
Cystic fibrosis is frequently encountered in the
Middle East, despite a misconception that it is rare in
the region.98,99 New mutations for this pathology are
being identified.100 The need of genetic counselling,
prenatal diagnosis and future screening is primordial
to stem the incidence of this severe lung condition.
The significance of this disease compounded by the
fact that the treatment option of lung transplantation
is not available in the Middle East (Fig. 3).
Ciliary dyskinesia
Formerly known as immotile cilia syndrome, ciliary
dyskinesis is a cause of recurrent pulmonary infec-
tions and bronchiectasis. It has been reported in
many families in the Middle East and the locus for its
defective gene has recently been identified.101
Alpha-1 antitrypsin deficiency
Although alpha-1 antitrypsin deficiency (AAT) is more
prevalent in the Caucasian population of European
ancestry, a recent study by De Serres demonstrated
that its distribution covers various ethnic groups
including Arabs.102 AAT predisposes to premature
emphysema especially in cigarette smokers, recurrent
lung infections and bronchiectasis.103 Genetic coun-
selling can play an important role in preventing the
occurrence of this condition.
Sarcoidosis is also not uncommon in Middle East due
to the large immigrant population from Africa. The
disease is 16 times more common in African popula-
tions, and Africans affected have more severe disease
and extrathoracic involvement.104 The prevalence of
sarcoidosis in the Middle East is not known but it
has been described in middle easterners, especially
women.105 Sarcoidosis can affect both upper respira-
tory airways106 and/or lower respiratory tract causing
lung functional impairment,107 and can mimic
chronic beryllium disease.108 A retrospective study
involving 104 Arabic patients revealed that 77% of
newly diagnosed sarcoidosis patients were in their
fifth decade or older at the time of presentation with a
female : male ratio of 2:1.107 The main symptoms were
dyspnoea (76%), cough (72%) and weight loss (33%).
Prominent hilar and mediastinal adenopathies are
common radiographical findings (Fig. 4). Complica-
tions can arise from the disease itself or from corti-
costeroid therapy.109
Patients with IPF in the Middle East have similar pre-
sentations110 as in other parts of the world. Alhamad
et al. prospectively evaluated 52 patients (61.5% men)
with IPF over a period of 4 years and found that
Figure 3 Cystic fibrosis with dilated airways throughout
both lungs.
Figure 4 Enlarged hilar and mediastinal lymph nodes in
a case of sarcoidosis.
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Respirology (2011) 16, 755–766
the mean age at the time of diagnosis was 55.4
11.9 years and 42.3% were smokers. The mean dura-
tion of symptoms at time of diagnosis was 2.1
0.9 years. Digital clubbing was present in two-thirds
of patients. The mean FVC, TLC and DLCO were 57%,
64.4%, 55% of predicted normal respectively. The
median survival was 92 months but those with finger
clubbing had a fivefold increase in mortality.111 Lung
transplantation, used successfully for IPF, is not yet
available in the Middle East.112
Sleep disorders
Sleep medicine is a new subspecialty in the Middle
East; hence the clinical services, patient education,
staff training and hospital administrative systems are
often inadequate to support the clinical load. Aware-
ness about sleep disorders among clinical practitio-
ners and patients in general is very limited. A survey
of primary health care physicians year in Riyadh
reported that 43% of primary care physician did not
realize the existence of sleep medicine as a specialty,
40% felt that sleep disorders were not common and
38% did not know to whom they should refer their
patients.113 Similar findings were reported by Gelir
et al. from Turkey where 47% of the physicians
regarded themselves as having little knowledge on
sleep disorders and only 45% of physicians correctly
answered questions on common sleep disorders.114
The prevalence of sleep apnoea (SA) among
middle-aged Saudis were estimated to be 33% in men
and 39% in women in the primary care study using
the Berlin questionnaire.115,116 Another study from
Jordan revealed that 16.8% of subjects were at risk
of SA and 34% of subjects reported frequent daytime
fatigue or tiredness.117 The prevalence of SA among
Saudi women seems to be higher than that reported
in other countries.115,116 This could be directly attrib-
uted to the high prevalence of obesity in Saudi
women; as 50% of Saudi women between 40 and
49 years of age have a BMI 30 kg/m2.118
Substantial challenges exist in the establishment of
sleep medicine as a specialty in the Middle East. The
lack of qualified sleep specialists and trained techni-
cians and the shortage of sleep laboratories mean that
patients are often managed by non-specialists with
inadequate experience. No regularity bodies exist to
govern licensing and professional competences. One
survey in Saudi Arabia reported that lack of trained
sleep technicians was a major obstacle for the estab-
lishment of a sleep medicine service in 80% of the
surveyed hospitals. Another survey from Saudi Arabia
reported a per capita polysomnography study rate
of 7.1 per 100 000 people per year, compared with
18–427 in developed countries. There were only 0.06
beds designated for sleep studies per 100 000 people
in the Kingdom of Saudi Arabia, significantly lower
than figures (0.3–1.5) in developed countries.119
A lack of public knowledge about sleep disorders
and the limited support for patients regarding dis-
pensing, funding, use and maintenance of the CPAP
machines all hinder the development of sleep ser-
vices and patient compliance. One study from Oman
found only 36% patients received CPAP titrations and
treatment after diagnosis of SA.120 Fidan et al.from
Turkey reported that only 52.9% of the patients used
their CPAP regularly.121
Lung malignancies
Lung cancer is common in the Middle East. A study of
cancers in the Gulf countries found that lung cancer
ranked first among all malignancies among men and
second among Bahraini women.122 The incidence is
steadily rising among men and women; cigarette
smoking is the main risk factor for this condition.123
Mesothelioma is also encountered secondary to
asbestos exposure.28,124
A large Turkish study from a decade ago showed
clear male predominance and squamous cell type
being the most frequent.125 A more recent study con-
ducted in the same country, this time done on
women; show the preponderance of adenocarci-
noma, followed by small cell lung cancer, then squa-
mous cell cancer, followed by non-small cell lung
cancer.126 Treatments vary greatly depending on the
type and stage of lung cancer.
Pleural diseases
A wide spectrum of pleural diseases is encountered in
the Middle East. Some of those specific to the region
are highlighted below.
Pneumothoraces are usually traumatic in aetiology
and can be seen at a large scale in countries
prone to earthquakes such as Iran and Turkey.127
Spontaneous pneumothorax can occur with emphy-
sematous lungs or can be idiopathic in origin.128
Occasionally, ruptured hydatid cyst can lead to a
Exudative pleural effusions are also common and
infectious causes especially tuberculous effusions
are prevalent.130 Adenosine deaminase is commonly
employed in the workup of tuberculous pleuritis.131,132
Many exudative pleural effusions of unknown aetiol-
ogy were empirically treated with anti-tuberculous
therapy in the Middle East.
Malignant mesothelioma is a major public health
problem in parts of the Middle East. Besides occupa-
tional exposure, environmental asbestos exposure is
prevalent.28 One cause of mesothelioma unique to the
Middle East is erionite, a naturally occurring fibrous
mineral prevalent in Anatolia, Turkey.133
Other lung conditions of special relevance to
the Middle East
Low birth weight/prematurity and related
lung complications
Low birth weight is prevalent in many parts of the
Middle East. A recent largeYemeni study looking at 62
168 births found a high rate of 24.6% preterm babies
Respiratory disorders in the Middle East 761
© 2011 The Authors
Respirology © 2011 Asian Pacific Society of Respirology
Respirology (2011) 16, 755–766
with low birth weight. Mortality rate among low
birth weight neonates was very high and respiratory
distress syndrome (RDS) accounted for 63.8% of
Respiratory distress syndrome predisposes to
bronchopulmonary dysplasia in very low birth weight
neonates. In a Turkish study, nosocomial infections,
the presence of acidosis at admission, surfactant
administration and the presence of patent ductus
arteriosus were associated with the development
and/or severity of bronchopulmonary dysplasia.135
Antenatal corticosteroids are useful in reducing mor-
tality from RDS. An Iranian study showed that babies
whose mothers were treated with dexamethasone
were less likely to develop RDS (18.6% vs 35.9% in
those not treated), require neonatal intensive care
unit admission (12.9% vs 21.1%) or die from RDS
(5.7% vs 14.8%).136
Foreign body aspiration
In the Middle East, foreign body aspiration occurs
more commonly in children, especially under 3 years
of age.137 Organic materials such as nuts, seeds and
bones are often reported as the aspirated foreign body
(Figs 5,6).137,138 Up to 10% of children might not have
any definite history.139 Rigid bronchoscopy is success-
fully used in children to remove the foreign bodies in
up to 99% of the cases.140
Foreign body aspiration is rare in adults but, in
recent years, aspiration of pins (used to secure head-
scarves) has been commonly described in Middle
Eastern women.141,142 They often wedge at the right-
sided airways and can be successfully removed by
rigid bronchoscopy.141 In experienced hands, straight
metallic pins and other foreign bodies in adults can
be safely removed using flexible bronchoscopy.142
Chest trauma in Middle East
Chest trauma is a leading cause of morbidity and
mortality in the Middle East, especially from road
traffic accidents. From two large series from Tur-
key,143,144 blunt injury, mostly related to traffic acci-
dents, accounted for two-thirds of the chest injuries.
Men were more commonly involved (average age of
presentation was 32 years) and 35% of patients had
other organs involved beside chest trauma. Tube tho-
racostomy was needed in 40% of cases and thorac-
otomy in 6%. Overall mortality was 9.3% (6.8% in
blunt, 1.4% in penetrating and 17.7% in associated
organ traumas).
A report from Jordan145 also identified road traffic
accidents as the most common aetiology of chest
injuries (77%), followed by firearm injuries (17%).The
mean hospital stay was 11.1 days and the mortality
rate was 8.8%. Knife stabbing followed by gunshots
were the commonest aetiologies of penetrating chest
Road traffic accidents were also the most frequent
cause of chest trauma (62%) in children of Saudi
Arabia.147 The median age in that series was 9 years
and gunshot wounds and stab wounds were
also common. Associated head (19%) and intra-
abdominal injuries were frequent. Half (49%) of the
children required interventions: 37% with tube thora-
costomy, 8% mechanical ventilation and 4% needed
Respiratory problems in Middle East can be unique
and cover a wide variety of pulmonary disorders, in
part owing to the large immigrant population and the
environmental conditions of this region.
The prevalences of smoking and obesity have
reached alarming heights in the Middle East and
the associated lung diseases now present a major
health burden to the medical system. Huge number of
vehicles and speeding have contributed to increasing
number of road traffic accidents and chest traumas.
Figures 5 and 6 CXR showing right lung collapse and
piece of bone removed from the right main bronchus of a
54-year-old woman.
A Waness et al.762
© 2011 The Authors
Respirology © 2011 Asian Pacific Society of Respirology
Respirology (2011) 16, 755–766
Tackling these health issues will require an inte-
grated approach involving public health, primary care
as well as specialist pulmonology input, taking into
consideration the unique cultural and environmental
factors to ensure effective management and compli-
ance to medical care.
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... [Effect of forest fires on soil properties. NEXO Agrop., 2(1-2), [10][11][12][13][14]. ...
... 13 C-NMR spectrum of degraded gum B of A. macracantha gum. G = β-Dgalactose. ...
... 13 C-NMR spectrum of saman gum. U = Uronic acids A = α-Larabinofuranose G = β-D-galactose. ...
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The chapter exposes the performance of Acacia melanoxylon wood for pulping production, regarding yields and kappa number but also the pulp and paper properties. The use of spectroscopy techniques is also emphasized.
... [12][13][14] Intuitively, it would seem appropriate to simply replicate one of these programs in Saudi Arabia. However, as the spectra of respiratory diseases in the Middle East differs from that in more temperate regions, [15] Western POCDLUS curricula may not be applicable to Saudi Arabia. Justification for the high initial cost of developing a POCDLUS service requires confirmation that POCDLUS is applicable to the current practice of IM in Saudi Arabia. ...
... As POCDLUS can greatly facilitate the management of COVID-19 globally, the use of POCDLUS by internists and pulmonologists has increased exponentially in the past few months. [1] However, the spectra of respiratory [15] A justification for the significant start-up costs of a POCDLUS service requires confirmation that this technology is applicable to the practice of medicine in Saudi Arabia. This study, therefore, describes IM residents' perceptions of the applicability of four indications for diagnostic POCDLUS to the practice of IM at a Medical City in Saudi Arabia. ...
... [10] This may be because POCDLUS findings, whilst useful, are relatively nonspecific. Although there are regional differences in the differential diagnosis of pleural effusion, [15] for example, the use of POCDLUS to detect effusions is universally applicable to the practice of IM. This observation suggests that the international standardization of basic POCDLUS training may be possible and curricula developed in other countries may be relevant to internists in Saudi Arabia. ...
CONTEXT: Coronavirus disease 2019 (COVID-19) has put a spotlight on point-of-care diagnostic lung ultrasound (POCDLUS). However, the spectra of respiratory disease and resources available for investigation vary internationally. The applicability of POCDLUS to internal medicine (IM) practice in Saudi Arabia and the current use by Saudi physicians are unknown. AIMS: The aim of the present study was to determine the applicability of POCDLUS to IM practice in Saudi Arabia and quantify the residents' current skills, accreditation, and use of POCDLUS. METHODS: A questionnaire was distributed to the IM residents at our institution to assess their knowledge, use of POCDLUS, and their perceptions of its applicability in IM. STATISTICAL ANALYSIS: Standard descriptive statistical techniques were used. Categorical data, presented as frequency, were compared using the Chi-squared test. The Likert scale responses, presented as mean ± standard deviation, were compared with a Student's t-test. RESULTS: In total, 100 residents participated (response rate 92.6%) and reported that POCDLUS was applicable to their practice. Identifying pleural effusions was most applicable. A small proportion (n = 7) had received training, nine used POCDLUS regularly, none were accredited and the overall self-reported level of knowledge was poor. CONCLUSIONS: Whilst POCDLUS is applicable to IM practice in Saudi Arabia, the significant skills gap preclude the provision of a POCDLUS service. As COVID-19 can cause an interstitial syndrome, our pandemic preparation response should include POCDLUS training. The current study is supported by a similar Canadian study and the international standardisation of POCDLUS training may be feasible. The findings of the current study may facilitate the development of POCDLUS training programs for internists throughout Saudi Arabia.
... [Effect of forest fires on soil properties. NEXO Agrop., 2(1-2), [10][11][12][13][14]. ...
... 13 C-NMR spectrum of degraded gum B of A. macracantha gum. G = β-Dgalactose. ...
... 13 C-NMR spectrum of saman gum. U = Uronic acids A = α-Larabinofuranose G = β-D-galactose. ...
... [Effect of forest fires on soil properties. NEXO Agrop., 2(1-2), [10][11][12][13][14]. ...
... 13 C-NMR spectrum of degraded gum B of A. macracantha gum. G = β-Dgalactose. ...
... 13 C-NMR spectrum of saman gum. U = Uronic acids A = α-Larabinofuranose G = β-D-galactose. ...
... Onions and cosmetic shops are infected with Aspergillus Niger, which produces sooty earth.A. Niger infection of onion seedlings can come systemic, appearing only when the conditions are right.A. Niger produces a frequent onion postharvest complaint in which black conidia can be seen between the bulb's scales 13 . Peanuts and grapes are also affected by the fungus.Aspergillus Niger is less likely than other Aspergillus species to beget mortal complaint. ...
The purpose of our study is to focus on the causes of infectious diseases and on the reactions of the host to the pathogens. Although the advent od antibiotics and vaccines has certainly taken the dread out of many infectious diseases, the treat of infection is still a fact of life. New pathogens are constantly being discovered, strains of old ones have developed resistance to antibiotics, making therapy more and more difficult, while incurable diseases like AIDS, rabies etc. are still with us. Infectious diseases have been known for thousands of years, although accurate information on their etiology has only been available for about a century. We focussed on the broad knowledge of the etiologic organisms causing disease and the pathogenetic mechanisms leading to clinically manifest infections into its users. This knowledge is needed for every individual and a prerequisite for the diagnosis, therapy and prevention of infectious diseases.
... In a study with 501 smokers in three major Saudi cities, the prevalence of COPD was 14.2% [16]. Additionally, many individuals in Saudi Arabia, also report a history of tuberculosis, persistent asthma, and respiratory-tract infections throughout infancy, which are all considered risk factors for COPD [17]. Further, non-smoking variables, such as biomass fuel, dusts, gases, and outdoor air pollution, are also commonly contributing to the increased burden of COPD in Saudi Arabia [18]. ...
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Background The available data to determine the chronic obstructive pulmonary disease (COPD) burden in Saudi Arabia are scarce. Therefore, this study closely examines and tracks the trends of the COPD burden in Saudi Arabia from 1990 to 2019 using the dataset of the Global Burden of Disease (GBD) 2019. Methods This study used the GBD 2019 dataset to analyse the COPD prevalence, incidence, morbidity and mortality rates in the Saudi Arabian population from 1990 to 2019, stratified by sex and age. The age-standardised rate was used to determine the prevalence, incidence, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life years (DALYs) and deaths. Results In 2019, an estimated 434,560.64 people (95% Uncertainty Interval (UI) 396,011.72–473,596.71) had COPD in Saudi Arabia, corresponding to an increase of 329.82% compared with the number of diagnosed people in 1990 [101,104.05 (95% UI 91,334.4–111,223.91)]. The prevalence rate of COPD increased by 49%, from 1,381.26 (1,285.35–1,484.96) cases per 100,000 in 1990 to 2,053.04 (1918.06–2194.29) cases per 100,000 in 2019, and this trend was higher in males than females. The incidence rate of COPD in 2019 was 145.06 (136.62–154.76) new cases per 100,000, representing an increase of 43.4% from the 1990 incidence rate [101.18 (95.27–107.86)]. In 2019, the DALYs rate was 508.15 (95% UI 434.85–581.58) per 100,000 population. This was higher in males than females, with a 14.12% increase among males. In 2019, YLLs contributed to 63.6% of DALYs due to COPD. The death rate due to COPD was 19.6 (95% UI 15.94–23.39) deaths per 100 000 in 2019, indicating a decrease of 41.44% compared with the death rate in 1990 [33.55 deaths per 100 000 (95% UI 25.13–47.69)]. In 2019, COPD deaths accounted for 1.65% (1.39–1.88) of the total of deaths in Saudi Arabia and 57% of all deaths caused by chronic respiratory diseases. Conclusion Over the period 1990–2019, the prevalence and incidence of COPD in Saudi Arabia have been steadily rising. Even though COPD morbidity and death rates have been decreasing, they remain higher in men and older age. The holistic assessment and interventions with careful attention to optimising the community-based primary care management, such as screening for early diagnosis, smoking cessation programs and pulmonary rehabilitation, are likely to be the most successful strategies to reduce the burden of COPD in Saudi Arabia.
... However, the restrictive defects and low diffusion shown in this study are similar to those from other studies in the region. 15,16 A major limitation of the current study was that pulmonary defect patterns could not be meaningfully considered as PD patterns. Moreover, isolated diffusion impairment can be documented in non-pulmonary diseases such as cardiac failure; however, this issue was not considered in the current research. ...
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Objectives: This study aimed to document the distribution of PFT outcomes among adult Omani patients. There is limited information regarding the distribution of pulmonary diseases (PD) in Oman. Pulmonary function test (PFT) outcome patterns could indicate an indirect distribution of PD. Methods: This retrospective cross-sectional study was conducted from January to December 2015 at a tertiary hospital in Oman. A total of 1,118 adults referred for PFTs during this period were included. Results: There were 605 (54.1%) female and 513 (45.9%) male patients. The mean age of the patients was 47.11 ± 18.1 years. Most patients underwent spirometry with reversibility (36.8%) or full lung function testing with reversibility (29.7%). Among the 1,064 patients with conclusive PFT outcomes, 39.9% had normal findings, 26.1% had obstructive defects, 19.6% demonstrated restrictive defects and 10.6% had mixed obstructive/restrictive defects. Conclusion: This study generated important preliminary data regarding PFT outcomes (defects) in Omani patients.
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Due to their prevalence, respiratory diseases have attained great attention from the historical time. Furthermore, it has been explored in a new dimension due to recent viral outbreaks such as COVID-19. Even though modern medicine treats the majority of respiratory ailments, it is reported that the majority of people (≥ 80%) who suffer from respiratory disorders do not take medication for their conditions, and a considerable number of people still believe in and use herbal medicines. Herbal therapies have been utilized all over the world for thousands of years. Traditional herbal treatment has long been seen as a valuable practice in Saudi Arabia, long before modern medicine. Due to its location in the desert and humid climate, Saudi Arabia suffers from a high rate of respiratory illnesses caused by dust, pollens, and viruses. Several published literature have employed different plants and plant products for respiratory problems, but there has yet to be a single, complete study centered on Saudi Arabia. In this review, 41 plants were identified, which has complete details regarding their usage in traditional practice for respiratory disorders. A thorough investigation was conducted and the results were detailed.
This article reviews the characteristics and definitions of desert dust and respiratory effects of its exposure on human-health. This chapter includes the possible risks and mechanisms associated with the exposure to desert dust. Desert dust is a mineral dust that, together with various air pollutants such as heavy metals, polyaromatic hydrocarbons, microorganisms, and secondary products, affects human health. In addition to the source of dust in arid areas, it can fly into the air and affect downwind regions. A broad overview described dust science and exposure index, animal experiments, immune mechanisms, epidemiological studies, preventive measures, and possible future respiratory diseases.
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Context: Coronavirus Disease 2019 (COVID-19) put a spotlight on focused cardiac ultrasound (FoCUS). However, the spectra of cardiac disease, and the resources available for investigation vary internationally. The applicability of FoCUS to internal medicine (IM) and critical care medicine (CCM) practice in Saudi Arabia and their current use of FoCUS are unknown. Aims: To determine the applicability of FoCUS to IM and CCM practice in Saudi Arabia and quantify the residents’ current proficiency, accreditation and use of FoCUS. Methods: A questionnaire was distributed to the residents in IM and CCM at our institution to determine their proficiency, use of FoCUS, and perceptions of its applicability. Results: In total, 110 residents (IM 100/108; CCM 10/10) participated (Response rate 93.2%) and reported that FoCUS was very applicable to their practice, most specifically for pericardial effusion, right heart strain, and left ventricular function. Two IM residents had received postgraduate training, ten used FoCUS regularly, none were accredited and overall selfreported proficiency was poor. In contrast all CCM residents had received postgraduate training and reported regular use of FoCUS. Two were accredited. Conclusions: Whilst FoCUS is applicable to IM practice in Saudi Arabia, significant skills gaps exist. The skills gap in CCM is lower but unaccredited practice is common. Our residents’ responses were similar to those from Canada. Thus, international standardization of FoCUS training could be considered.
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Obesity and overweight are well known risk factors for coronary artery disease (CAD), and are expected to be increasing in the Kingdom of Saudi Arabia (KSA) particularly among females. Therefore, we designed this study with the objective to determine the prevalence of obesity and overweight among Saudis of both gender, between the ages of 30-70 years in rural as well as in urban communities. This work is part of a major national project called Coronary Artery Disease in Saudis Study (CADISS) that is designed to look at CAD and its risk factors in Saudi population. This study is a community-based national epidemiological health survey, conducted by examining Saudi subjects in the age group of 30-70 years of selected households over a 5-year period between 1995 and 2000 in KSA. Data were obtained from body mass index (BMI) and were analyzed to classify individuals with overweight (BMI = 25-29.9 kg/m2), obesity (BMI >/=30 kg/m2) and severe (gross) obesity (BMI >/=40 kg/m2) to provide the prevalence of overweight and obesity in KSA. Data were obtained by examining 17,232 Saudi subjects from selected households who participated in the study. The prevalence of overweight was 36.9%. Overweight is significantly more prevalent in males (42.4%) compared to 31.8% of females (p<0.0001). The age-adjusted prevalence of obesity was 35.5% in KSA with an overall prevalence of 35.6% [95% CI: 34.9-36.3], while severe (gross) obesity was 3.2%. Females are significantly more obese with a prevalence of 44% than males 26.4% (p<0.0001). Obesity and overweight are increasing in KSA with an overall obesity prevalence of 35.5%. Reduction in overweight and obesity are of considerable importance to public health. Therefore, we recommend a national obesity prevention program at community level to be implemented sooner to promote leaner and consequently healthier community.
Between 1946 and 1990 uranium mining was undertaken on a large scale in East Germany. This study evaluates the proportional lung cancer risk of German uranium miners from radon, quartz, and arsenic exposure during mining operations at the WISMUT Corporation. The database of the WISMUT tissue repository and a comprehensive job-exposure matrix were used to compare exposure levels of lung cancer cases with deaths from diseases of the circulatory system for risk analysis. In addition, the ratio of lung cancer cases was compared to cases from diseases of the circulatory system to the corresponding ratio in the general population. The proportional lung cancer mortality of German uranium miners was 2.9-fold higher than in the general population of East Germany. Cumulative radon, quartz, and arsenic exposure were determined as risk factors for lung cancer among German uranium miners, where silicosis modified the risk of cumulative radon and quartz exposure. Silicotics were exposed to higher levels of quartz, radon, and arsenic than nonsilicotics. Because selection of the study population was based on a tissue repository, the results need to be interpreted with caution.
Inherited DisordersAcquired DisordersReferences
Objective: The aim of this study was to investigate, for the first time, the factors associated with resistance to antituberculous drugs in Saudi Arabia, and to follow the long-term trends in drug resistance. Methodology: A retrospective study of patients with positive Mycobacterium tuberculosis recorded at the Riyadh Tuberculosis Center in 1990 was undertaken. The resistance figures from the same centre for the period July 1996 to June 1997 were reviewed for comparison. Results: Resistance was significantly higher in those previously treated (71%) than in those who denied previous treatment (34%). There was a trend towards association of resistance with cavitatory, multilobar, and acid fast bacilli-positive cases. Nationality (Saudis, Yemenis, others) had no significant effect on resistance. The Riyadh Region now has the same high prevalence of rifampicin resistance as previously reported in the Western Region of the Kingdom. The figures on resistance for the years 1986-88, 1990, and 1996-97 were: isoniazid 19.5/13.8/11.1%, rifampicin 10/20.7/24.6%, streptomycin 5/22/27.4%, ethambutol 3.7/3.9/1.8%, respectively. The reduction in isoniazid and ethambutol resistance coincided with a rise in resistance to rifampicin and streptomycin. We speculate that this resulted from the fact that isoniazid and ethambutol are restricted only to the treatment of tuberculosis and cannot, by law, be dispensed by general practitioners or private pharmacies. Rifampicin and streptomycin, however, are widely used for brucellosis; an endemic disease in Saudi Arabia where up to 12 weeks of rifampicin therapy is recommended. Conclusions: There has been a significant increase in rifampicin and streptomycin resistance in Saudi Arabia over the last 10 years. Possible causes include poor compliance and wide use of these two drugs for non-tuberculosis conditions. These findings could jeopardize the benefits of the directly observed therapy short course policy which is being implemented in Saudi Arabia. Consideration should be given to prohibiting the routine use of rifampicin for the treatment of brucellosis.