key: cord-0010244-bnz244jy authors: nan title: POSTER PRESENTATION date: 2016-11-11 journal: Respirology DOI: 10.1111/resp.12939_15 sha: a80ad731216ff8fbac734eb5f7029ded6627fea4 doc_id: 10244 cord_uid: bnz244jy nan treated promptly with empiric antibiotics. Protocol for antibiotics initiation is based on the severity evaluation. Mild pneumonia should be treated with beta-lactam or macrolide or fluoroquinolone. Moderate pneumonia should be started with parenteral cephalosporin plus fluoroquinolone. Carbapenem plus fluoroquinolone are recommended for severe pneumonia. Beta-lactam plus beta-lactamase inhibitors are selected for pneumonia with drug-resistance pathogens. Patients should be also evaluated for pseudomonal risk factors. Patients should be switched from parenteral antibiotics to oral antibiotics after their symptoms improve, they are afebrile, and they are able to use oral medications. Patients should receive pneumococcal vaccination, influenza vaccination, and tobacco cessation counseling if eligible. Background and Aims: RSV is a common cause of respiratory tract infection (RTI) in children and can induce reactive airway disease. Epidemiological evidence supports that it can cause RTI in adults; however the data is limited in Thai patients. Methods: A cohort study was conducted to determine clinical manifestations of RSV infection in adult hospitalized patients. Spirometry and methacholine challenge test were also performed after recovery from RSV infection 1 -12 weeks in patients who had no preexisting airway diseases Results: Of 69 patients were included in the study with mean aged of 72 (58 -81) years. All except one had underlying diseases. Pulmonary diseases (28%), cardiovascular diseases (26%), diabetes (26%) and immumocompromised hosts (22%) were common co-morbidities. Asthma was the most common pre-existing pulmonary diseases (asthma 12%, COPD 4%, previous tuberculosis treatment 6% and bronchiectasis 6%). Most common presenting symptoms of RSV infection were cough 62 (90%), dyspnea 59(86%) and fever 54 (78%). Median duration of illness was 3 days. Rhonchi and/or wheezing (84%) were the most common physical findings. Fever was found 46% of patients. Thirty one patients (45%) were diagnosed pneumonia. The most common abnormal radiographs were bilateral interstitial opacities. Twenty four patients (35%) developed respiratory failure. Patients with respiratory failure were higher mortality rate and longer hospitalization than those without respiratory failure. Thirteen patients underwent spirometry, 3 of them had obstruction. Eight patients who had normal spirometry further underwent methacholine challenge test, 3 had borderline and 1 had bronchial hyperresponsiveness. Conclusions: Cough, dyspnea and fever are the most common presenting symptoms of RSV infection in adult hospitalized patients. Wheezing and rhonchi commonly found in patients. RSV infection can cause airway obstruction and bronchial hyperresponsiveness. Background and Aims: A myriad of etiologies have been linked to the adult cervical lymphadenopathy. Here, we report a case of HIV-negative adult presenting with recurrent cervical adenitis despite extensive workups and anti-tuberculous treatment. Resolution of the cervical adenitis was eventually achieved after commencing on treatment for nontuberculous mycobacterium (NTM) based on a single positive sputum culture. Results: A 29-year-old man (smoker) presented initially with cervical lymphadenopathy of one-month duration but had repeated inconclusive lymph node fine needle aspiration cytology and excision biopsy results and negative tuberculosis workup. He was then initiated on antituberculous therapy.Despite being compliant to his anti-tuberculous medication, he suffered frequent recurrence of both new and old cervical adenitis with secondary bacterial infection on a few occasions. The patient was initiated on intravenous amikacin, clarithromycin and ciprofloxacin for non-tuberculous mycobacteria based on single positive sputum culture, exclusion of other possible causes and a possible history of treatment response to carbapenem in another medical institution. Subsequent review for the next twelve months showed no recurrence. Conclusions: Diagnosing cervical lymphadenopathy secondary to nontuberculous mycobacterial infection can be very challenging. A poor response to anti-tuberculous therapy should alarm clinicians to exclude other possibilities before considering this rare infection. To explore the risk factors and prognostic factors of invasive pulmonary aspergillosis (IPA) in patients with chronic obstructive pulmonary disease (COPD) Methods: We conducted a single-center, retrospective, case-control study of 88 COPD patients with IPA and 176 COPD control patients without IPA. It was carried out in the department of respiratory and critical care medicine in the First Affiliated Hospital of Wenzhou Medical University in China, From January 2008 to August 2015.The diagnostic criteria for IPA were adapted from Bulpa et al Results: There had 2034 AECOPD admissions, of which 205 (10%) had isolates of Aspergillus from LRT samples, with 107 cases diagnosed as colonization. 98 (4.8%) were confirmed with IPA, 88 were enrolled in the case group. The mortality rate of IPA in COPD was 40.9% (36/88). In multivariate analysis, Five variables were independent risk factors associated with IPA in COPD with statistical significance: duration of antibiotics longer than 10 days during admission (OR 15.09, 95%CI 3.57-63.91, P < 0.01), systemic use of steroids before admission (OR 5.46, , P 0.01), lymphocytes lower than 0.8 × 10 9 /L (OR 4.75, , P 0.04), temperature higher than 38 C (OR 9.57, 95%CI 2.26-40.61, P < 0.01) and worsening radiological findings (OR 5.46, 95% CI 1.17-25.48, P 0.03). Prognostic factors independently associated with IPA patients in COPD include mechanical ventilation (OR 5.24, , P 0.03), consolidation in chest imaging (OR 11.53, .01, P 0.02) and the duration of antifungal treatment (OR 0.95, 95%CI 0.90-0.99, P 0.02) Conclusions: Systemic use of steroids in the 3 months prior to admission, antibiotic treatment longer than 10 days, lymphocytes lower than 0.8 × 10 9 /L, temperature higher than 38 C, and worsening radiological findings are strong predictive risk factors associated with IPA in COPD. Consolidation in chest imaging, mechanical ventilation and short duration of antifungal treatment are associated with poor outcome in IPA with COPD Background and Aims: Williams-Campbell syndrome (WCS) is a rare disorder characterized by the congenital deficiency of cartilage in the subsegmental bronchi, leading to cystic bronchiectasis and airway collapse on expiration. It causes repeated airway infections from the first year of life, and many patients die of respiratory failure in childhood. However, the prognosis of patients who survived the childhood improves with age. Results: Case presentation:A 77-year-old woman was admitted to our hospital with a 1-year history of worsening dyspnea. She had productive cough, shortness of breath, and wheezing from infancy. Because of dyspnea, she could hardly play outdoors during childhood. When she was over 20 years old, her exertional dyspnea alleviated, and she got a welding job at an iron factory. Later, she married and gave birth. She had no history of tuberculosis, sinusitis, or smoking, and her mother had exhibited similar symptoms. Her oxygen saturation was 78% on room air. Her white blood cell count and C-reactive protein level were markedly elevated. Immunoglobulins and aspergillus antigen levels were within the normal range. Pseudomonas aeruginosa was detected in a sputum culture. CT revealed widespread cystic bronchiectasis in the subsegmental bronchi and the collapse of cystic areas on expiration. She was diagnosed with WCS. Administration of antibiotics was started. Conclusions: It is difficult to obtain pathology specimens by bronchoscopy showing the deficiency of cartilage in the bronchial wall. The diagnosis is based on characteristic CT findings and the exclusion of other possible causes, including cystic fibrosis, ciliary dyskinesia, immunoglobulin deficiency, and allergic bronchopulmonary aspergillosis. Her treatment aimed to control the respiratory infection for suppressing respiratory failure. The main bacteria causing adult respiratory infections are Pseudomonas aeruginosa, Mycobacterium avium, and Haemophilus influenzae. Long-term claritheromycin therapy is often performed on such a chronic infection in Japan. Early introduction of home oxygen therapy has been recommended. Background and Aims: Pulmonary cryptococcosis (PC) refers to acute or subacute infections of lungs caused by Cryptococcus, which occurs both in immunocompromised and non-immunocompromised hosts. The clinical manifestations of PC are variable and untypical, such as cough, fever, chest pain or no symptoms. The CT findings of PC may easily be confused with tumor or tuberculosis, leading to misdiagnosis. Cryptococcus latex agglutination test is commonly used in clinical practice as serological detection method for PC and shows high sensitivity and specificity. However, some PC patients are with negative LA test results. This study aimed to analyze the clinical manifestations, CT findings and host immune status of pulmonary cryptococcosis patients according to different latex agglutination test (LA) results. Methods: We retrospectively reviewed the clinical data of 378 patients with diagnosis of pulmonary cryptococcosis at Shanghai Pulmonary Hospital during a 12-years period. Patients were categorized according to their latex agglutination test results, and the different clinical characteristics were analyzed. Results: There were 244 patients with positive LA results and 134 patients with negative LA results. The average age of LA positive group was younger than the other. Immune-compromised hosts and patients with basic disease or risk factors were more likely to present positive LA result. Patients with negative LA results often had no symptoms or signs and their CT findings presented solitary nodule or mass. While LA positive patients had variable symptoms such as cough, fever, dyspnea, etc. A great diversity of chest CT manifestations were shown in LA positive patients, such as multiple nodules and masses, patchy shadows, interstitial infiltrates and diffuse granular shadows. Patient with solitary nodule or mass had lower titers than other types. Conclusions: There were different clinical characteristics between LA positive and negative patients. The LA test results were associated with clinical manifestations, CT findings and host immune status of pulmonary cryptococcosis patients. Background and Aims: Nocardiosis is an uncommon cause of pneumonia that primarily occurs in immunocompromised patients and generally implies poor prognosis. Past reports have described the Computed Tomography (CT) features of pulmonary nocardiosis, usually various combinations of nodule/mass, ground-glass opacity, interlobular septal thickening, bronchial wall thickening, consolidation and cavitation but the findings are often multiple and non-specific. We report a case caused by a rare strain of Nocardia species with atypical radiological presentation. Methods: Case Report: A 75 year-old Caucasian male traveler from Northern Australia, with known diabetes mellitus, chronic obstructive pulmonary disease, and congestive heart failure, was transferred to our hospital with gradual onset of dyspnea during a cruise tour. He was septic on arrival with respiratory failure and had suppurative skin lesions on both arms. CT scan showed randomly distributed miliary shadows of upper lobe predominance and multiple nodules of various sizes in both lungs. Wound cultures grew Nocardia species, later identified as Nocardia terpenica by 16S rRNA sequencing. For its known resistance to co-trimoxazole, treatment selected consisted of intravenous meropenem, minocycline, and linezolid. Following improvement these were changed to oral clarithromycin and minocycline. Results: Discussion: There is very limited information concerning Nocardia terpenica infection and our patient is the only case to be isolated from a non-Japanese individual since its first description in 2007. The miliary pattern of lung shadows often suggests infections such as miliary tuberculosis and invasive fungal diseases, but disseminated nocardiosis was diagnosed on the basis of wound cultures and response to treatment. Such miliary or diffuse granular patterns for nocardiosis were scarcely reported upon literature search. Conclusions: Nocardiosis is an important differential diagnosis for pneumonia presenting with miliary lung shadows especially in conjunction with pre-existing lung disease or the immunocompromised. Prompt recognition would enable laboratory awareness and lead to early optimal management. Chung-Ang University, Internal medicine, Seoul, Republic of Korea, and 2 Gimpo Woori Hospital, Internal medicine, Seoul, Republic of Korea Background and Aims: Although Mycobacterium avium complex (MAC) lung disease does not need immediate treatment, long term natural course of MAC lung disease without treatment was not well established. Therefore, we want to identify the long term natural course of the nodular bronchiectatic form of MAC lung disease without treatment by analyzing serial chest computed tomograph (CT) findings. Methods: Of 124 patients with MAC lung disease, we selected 40 untreated nodular bronchiectatic form MAC lung disease patients who had serial CTs at least 42 months interval (mean 6.2 years). Chest radiologist reviewed retrospectively initial and last CT scans. Each CT study was assessed for the presence and extent of bronchiectasis, cellular bronchiolitis, consolidation, cavity and nodule (maximum score, 30). Results: Of 40 patients, 36 patients (90.0%) progressed in the overall total score and it showed statistically significant (overall difference 4.95, p < 0.01). In bronchiectasis, 33 patients (82.5%) increased the number of lung segments involved after follow-up, and the mean initial and follow-up number of lung segments involved CT scans was 6.65 and 9.65, respectively ( p < 0.01). In cellular bronchiolitis, 36 patients (90.0%) increased the number of lung segments involved, and the mean initial and follow-up number was 8.05 and 12.03, respectively (p < 0.01). Conclusions: Without treatment, 90.9% of patients demonstrate progressive disease on serial CT over a mean follow-up period of 6.2 years. Background and Aims: Invasive pulmonary aspergillosis is an opportunistic mycosis, difficult to diagnose. Furthermore, invasive pulmonary aspergillosis and aspergillus empyema both exist in one man is a rare and severe Aspergillus infection. Early detection and treatment may reduce the rate of mortality. Methods: A 63-year-old eastern Asian man developed invasive pulmonary aspergillosis, bronchopleural fistula and empyema, who suffered 6 years of hemoptysis with bronchiectasis until the operation of lobectomy 10 years ago. After the operation, the biopsy examination revealed pulmonary aspergillosis. But, sadly, he did not receive anti-fungus therapy at that time. 10 years after lobectomy the patient complained of cough, expectoration and weight loss. After admission, a bronchopleural fistula from the right main stem bronchus to the pleural cavity and bilateral pulmonary consolidation were seen by computed tomography (CT) scan and bronchoscopy. Biopsy taken from the walls of the pleural cavity revealed a large pleural aspergillosis lesion. Results: Despite combined systemic anti-fungal treatment (voriconazole) and open window thoracostomy, the patient's condition were rapid exacerbated and died. Conclusions: We presented a rare case of invasive aspergillosis infection after a lobectomy 10 years ago. Anti-fungus therapy may necessary for the patient after remove the lesion of aspergillosis. Otherwise, A. fumigatus might exist in the body for a long period. Methods: Eight cases were diagnosed with M. kansasii at Izumi Municipal Hospital for 3 years. They were diagnosed on the basis of the results of sputum culture and/or bronchial washing. We retrospectively analyzed total 8 patients (2 females and 6 males) of mean age at 66 (AE11) years about clinical and radiological features. Results: Cough and sputum including hemoptysis were common (n = 6) in patients infected with M. kansasii. Previous lung tuberculosis and any other lung diseases (emphysema, pulmonary aspergillosis, and MAC infection) were seen in the majority. Except one female, all patients were smoker with mean Brickman index of 979. Chest CT scans revealed the location of main abnormalities were as follows: LtS 1+2 in two, LtS 3 + RtS 2 in one, RtS 1 in three, RtS 4 in one, and RtS 5 in one. Cavity formation was observed in 5 cases (62.5%). The mean maximum diameters of the cavity and the wall thickness were 56.8 mm and 7.8 mm, respectively. The lesion can be classified into 5 types as follows: large cavity of irregular form ≥ 40 mm in two, small of oval form < 40 mm in two, and tubular cavity in one, nodule /bronchiectasis in two, micronodule in one. Conclusions: We demonstrated that 8 cases were diagnosed with M. kansasii, including two female patients. There might be a connection between M. kansasii infections and smoking. CT findings revealed cavity formation in upper lobe predominantly, and the wall thickness of M. Kansasii was thinner than the one of tuberculosis. CT scans also showed nodule /bronchiectasis and micronodule lesions for M. Kansaii atypically. This study indicates M. Kansasii infections have some similar clinical features to MAC infections. Background and Aims: Actinomycosis is a rare infection which can mimic other diseases It often poses a challange in the diagnosis, but is treatable with high cure rate and good prognosis. We report 3 cases of lung actinomycosis which all differs in its presentation. Case 1: 39 years old lady was referred after an incidental finding of a cystic mass on the left upper lobe. She was asymptomatic with an unremarkable clinical examination. CT Thorax showed left upper lobe fibrosis with bronchiectasis and a cystic lesion (3.78 x 2.19 x 2.73 cm). Bronchoscopy showed cauliflower like mass which was biopsied. BAL cytology and histopathology of the lesion confirmed actinomycosis. She was subsequently commenced on oral Augmentin. Case 2: 59 years old housewife presented with significant loss of weight and lethargy. Clinical examination revealed a palpable mass over suprapubic area. CT scan showed a heterogenous pelvic mass and multiple lung nodules suggestive of metastasis. Further examination by gynaecologist revealed a retained intrauterine contraceptive device. She subsequently had a cervical biopsy which confirmed actinomycosis. She was then started on Augmentin for 6 months after which a repeated CT scan showed resolution of the lung nodules with marked clinical improvement. Case 3: 34-year-old man who was initially treated as community acquired pneumonia following a 3-month-history of productive cough, loss of weight and loss of appetite. However, 3 months after discharged from the hospital, he presented again with worsening respiratory symptoms and radiological evidence of a lung cavitation with intracavitary lesion resembling an aspergilloma associated with surrounding consolidation. Unfortunately he remained symptomatic despite on antifungal therapy.The repeat CT demonstrated persistent cavitating lesion with development of necrotizing pneumonia.He underwent lobectomy and the histopathological analysis of the resected specimen however revealed the diagnosis of actinomycosis. Conclusions: Actinomycosis can have many presentations. Biopsy of the area involved is vital to give the right diagnosis. Invasive zygomycosis can be fatal due to its complications and poor response to medical therapy. Pulmonary zygomycosis without other affected organs, were rarely described. Herein, we reported a 56-yearold man diagnosed of isolated pulmonary zygomycosis presenting concomitantly with diabetic ketoacidosis (DKA). He had chronic nonproductive cough without dyspnea, low-grade fever and weight loss for 3 months. He became deteriorated with developing diabetic crisis and being referred for further investigation. Past history revealed he had myocardial infarction and hypertension in 2010. He denied smoking, consumption of alcohol or illicit drugs. On examination, he was afebrile and respiratory rate was 18/min, pulse rate was 80/min, blood pressure was 120/60 mmHg. Lung auscultation was normal. Complete blood count revealed WBC of 5,810/mm 3 , PMN 45%, L 43%, M 8%, and Hb of 11.2 g/ dl. Chemistry showed creatinine of 1.13 mg/dl, fasting plasma glucose of 142 mg/dl, and liver function test was normal. Anti-HIV result was negative. Chest radiograph and computed tomography (CT) of the chest demonstrated a mass-like consolidation at apical segment of left upper lobe (LUL). Bronchoscopy with transbronchial biopsy was performed. Bronchoalveolar lavage fluid revealed numerous PMN without organisms on acid-fast and GMS stain. Histopathology showed acute necrotizing and granulomatous inflammation with fragments of fungal hyphae, morphologically consistent with zygomycosis. He refused symptoms of sinusitis or headache. ENT examination showed no evidence of sinusitis. CT of the brain and paranasal sinuses were normal. Liposomal amphotericin B (3 mg/kg/day) was given for two weeks before withholding because of worsening renal failure. He underwent LUL resection and liposomal amphotericin was resumed. He was improved and was discharged with posaconazole. In conclusion, we reported a patient with isolated pulmonary zygomycosis coincided with DKA. High suspicion and obtaining tissue histopathology for making early diagnosis and early surgical eradication with high-dose antifungal therapy are effective. Conclusions: The MERS-CoV can be transmitted via minimal contact in healthcare facilities. Therefore, we recommend early extended contact management, which may successfully reduce infection and prevent interhospital transmission. Background and Aims: Mucormycosis is an opportunistic fungal infection that occurs in immunocompromised host. Rhinocerebral infection is the most common form and usually occurs in poorly controlled diabetes patients especially who with diabetic ketoacidosis. Pulmonary mucormycosis, however, is a rare clinical presentation. Methods Results: This study reported a 62-year-old male teacher living in Chaiyaphum Province, presented with subacute fever, 10 kgs weight-loss and non-massive hemoptysis. He did not have symptoms of sinusitis. His underlying disease is a well-controlled diabetes mellitus, which is recently diagnosed for 6 months and no history of diabetic ketoacidosis. Physical examination revealed high-grade fever and bronchial breath sound with increased vocal resonance at left upper lung. Chest radiograph showed dense consolidation at left upper lung. The initial investigations were leukocytosis, normal blood sugar, no organisms on sputum Gram's stain and AFB smear. His melioid titer was 1:40. CT chest revealed area of consolidation at anterior segment of left upper lung and round-shaped hypodense lesion within the consolidation. He underwent bronchoscopy and transbronchial lung biopsy. The specimen showed broad non-septate hyphae with perpendicular branching. Pulmonary mucormycosis was diagnosed and treated with amphotericin B and followed by posaconazole. After 9 months of antifungal therapy, patient's symptoms improved but left upper lung lesion still persisted. Left upper lobe lobectomy was done. Conclusions: Then pulmonary mucormycosis should be concern in diabetic patients even though well controlled blood sugar. Patients with diabetes, the course may be more subacute than hematologic malignancy and organ transplant patients. The treatment is combination of anti-fungal therapy and surgical removal. Background and Aims: To detect the virus using Ploymerase Chain Reaction (PCR) technology in the hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and investigate prevalence of viral infection and the risk factors for AECOPD. Methods: We did a retrospective investigation of patients with AECOPD from May 2012 to May 2015, collected patient's basic information, clinical data and length of hospital stay, and analysis the virus epidemiology by using PCR. A logistic regression analysis was performed to investigate the risk factors. Results: 127 patients with AECOPD were included in this study. 52 episodes (40.94%) yielded positive viral PCR results, only one virus infection 36 episodes (28.34%), mixed infection 16 episodes (12.60%). AECOPD patients with a viral infection were associated with longer hospital stay (11.5 AE 0.96 vs 8.99 AE 0.42, P = 0.000). Multiple regression analysis showed that smoking (P = 0.029), diabetes (P = 0.001), respiratory failure (P = 0.049), frequency of exacerbations in previous year (P = 0.028) were the risk factors. Conclusions: Prevalence of respiratory viral infections was high in hospitalized patients with AECOPD. The length of hospital stay was longer in AECOPD patients from who a virus was isolated. Smoking, diabetes, respiratory failure, and frequency of exacerbations in previous year were the risk factors of a viral infection. Early identification of these risk factors may help reduce the incidence of AECOPD. Background and Aims: Introduction: Respiratory viruses are recognised for their ability to cause flu like symptoms and as exacerbators of asthma and COPD. However, the possible ability of viruses to exist symbiotically within the lung has not yet been explored. Aim: To determine the incidence of asymptomatic viral carriage in clinically stable asthma and COPD patients undergoing bronchoscopy. Methods: Asymptomatic patients (no recent or current viral symptoms) undergoing bronchoscopy were recruited. Exhaled breath (three forced expiratory maneuvers collected via a spirometry filter) and 10 mL bronchoalveolar lavage (BAL) were collected. A panel of respiratory viruses (Human Rhinovirus (HRV), Respiratory Syncytial Virus, Influenza A, Influenza B, Parainfluenza Virus 1, 2, 3 and Human Metapneumovirus (HMPV)) was assayed for using a sensitive RT-PCR in each matched sample. Virus detection was classified as positive following visualisation of weak or strong band. Results: Paired BAL and exhaled breath samples were collected from 49 patients with underlying respiratory conditions. 22 patients (45%) had respiratory secretions that were positive for our virus panel by RT-PCR. Only 1 patient reported symptoms of viral infection using the common cold questionnaire. In 3 patients, 2 viruses were detected concurrently (HRV, HMPV); while in 1 patient, 3 viruses were detected (HRV, Influenza B and HMPV). Using a nested Real Time PCR, 61% of exhaled breath samples and 57% of BAL samples showed Human Rhinovirus positivity at low viral loads. Conclusions: This preliminary analysis suggests that asymptomatic carriage of viruses may be more common that previously recognized and that respiratory viruses probably contribute to the microbiome of the lung especially in patients with asthma and COPD. The importance of the lung virome has not yet been established, thus further research hopes to investigate the interactions between resident bacteria and viral species. Background and Aims: Tuberculosis (TB) risk might be increased in diabetics by factors other than hyperglycemia, such as dyslipidemia. Host lipids are essential energy sources used by mycobacteria to persist in a latent TB state. A potential therapy targeting cholesterol catabolism of mycobacteria has been proposed, but the effects of cholesterol-lowering drugs on anti-TB still remains unclear. The purpose of this study was to determine the effects of ezetimibe, a 2-azetidinone cholesterol absorption inhibitor, on intracellular mycobacteria survival and dormancy. Methods: Intracellular mycobacteria survival was determined by measurements of ATP activity and colony-formation units. Gene expression profiles of hypoxia-induced dormant Mycobacterium tuberculosis (Mtb) were analyzed by real-time PCR. Flow cytometry and microscopy analysis were used to measure the lipid loads of human macrophages with or without ezetimibe treatment. QuantiFERON-TB Gold In-Tube (QFT-G-IT) assays were performed to diagnose latent tuberculosis infection. The levels of intracellular cholesterol/ triglyceride were measured by enzymatic fluorometric method. Results: Ezetimibe was capable of effectively lowering intracellular growth of Mtb and hypoxia-induced dormant Mtb. There was a significant decrease in Mtb growth in leukocytes from ezetimibe-treated patients with diabetes in terms of ATP levels of intracellular mycobacteria and CFU formation. Also, patients receiving ezetimibe therapy were associated with a lower prevalence of latent tuberculosis and had lower intracellular lipid contents. Conclusions: Ezetimibe, which is a currently marketed drug, holds promise as an adjunctive, host-directed therapy for TB. Background and Aims: Oropharyngeal tuberculosis, which is usually secondary to pulmonary tuberculosis, is a rare manifestation. We report a case of oropharyngeal tuberculosis in an old man at tuberculosis department for male (A 4 ) at Pham Ngoc Thach Hospital. Methods: A 62-year-old man patient, which was transferred from Oncology Hospital with diagnosis of oropharyngeal tuberculosis by biopsy, presented to the tuberculosis department (A4) with the chief complaints of sorethroat, loss of appetite, odynophagia and malaise. He was unable to swallow both liquids and solid food and had lost 10 kg of body weight within the last two months. Right cervical lymph nodes were detected. Oral and oropharyngeal examination showed that the posterior oropharyngeal wall mucosa was hyperemic and covered with multiple large, graywhite plagues of varying sizes. Chest radiograph showed nonhomogenous opacity of right lung and infiltration of left lung. Blood tests were within normal limits. HIV testing was negative. Sputum for AFB was positive and biopsy of lymph node showed tuberculosis. The patient was started on anti-TB treatment drugs (2SRHZE/1RHZE/5R 3 H 3 E 3 ). Results: After nearly 1 month on treatment, he was recovered from his symptoms and had normal appearing oropharyngeal mucosa. He was transferred to local TB unit for continuing treatment and follow-up. Conclusions: The possibility of tuberculosis should be keep in mind, especially in developing countries where the incidence of tuberculosis is high, in cases in which there are ulcer lesions of the oropharynx or oral cavity, not responding to antibiotic therapy. Biopsy is a necessary tool for diagnosis. Aga Khan University and Hospital, pulmonary medicine +, karachi, Pakistan, and 2 Aga Khan University and Hospital, internal medicine, karachi, Pakistan Background and Aims: Tuberculosis (TB) remains one of the leading infectious causes of morbidity and mortality worldwide. Its diagnosis relies on sputum smear whose sensitivity is low and sputum culture for AFB, which is time consuming. In past decade, diagnostic techniques based on nucleic acid amplification have been developed. This study was done to see the diagnostic accuracy of Xpert MTB/Rif in Bronchoalveolar lavage samples in our population. Methods: It was retrospective study. All patients who underwent bronchoscopy for evaluation of tuberculosis in pulmonary section of Aga Khan University hospital, Karachi from June 2014 to Dec 2015 were included. There files were reviewed after ethical approval. Total 480 files were reviewed and 88 patients met our inclusion criteria. Sensitivity and specificity of Xpert MTB/Rif with culture as reference method was determined. Results: Total 88 patients had confirmed pulmonary TB on cultures. 67% were male. The mean age was 38 AE 18 years. Only 25% had known history of TB contact. 26% were diabetic. Most common presenting complaints were fever (78%) and cough (64%). Mean duration of symptoms wAS 3 AE 1.5 months. Common chest x-rays findings were infiltrates (88%), cavitations (13%), and miliary pattern (7%). 3 patients had MDR TB on culture and 1 patient had XDR TB. AFB smear was positive in 57 (64%) patients having as sensitivity of 67% (95%CI 55%-77%) and specificity of 48% (95%CI 21%-73%). Xpert MTB/Rif was positive in 64 (73%) patients having a sensitivity of 86% (95%CI 76%-93%) and specificity of 93% (95%CI). Sensitivity of Xpert MTB/Rif for Rifampin resistance detection assay was 98% and Specificity was 99.9%. Conclusions: Xpert MTB/Rif detected TB cases more accurately and rapidly in BAL than smear with early detection of MDR TB. The use of Xpert MTB/Rif in BAL for TB diagnosis will lead to early and appropriate treatment of such cases in our setting. Background and Aims: A standard anti-tuberculosis drug regimen sometimes causes severe renal dysfunction. However, the detail remained unknown. We aimed to establish the standard management of renal dysfunction due to anti-TB drugs based on our retrospective data. Methods: We retrospectively analyzed the clinical feature of the active TB patients who developed into renal dysfunction after starting the standard anti-tuberculosis drugs in a single TB hospital. Results: Between 2010 and 2016, 15 active TB patients developed severe renal dysfunction after starting the TB treatment. The mean age was 61 AE 18 years old. 2 (13%) patients were female. The median onset time of renal dysfunction was 45 [range; 6-70] days. The mean serum creatinine level was 1.04 AE 0.91 mg/dl before starting anti-TB treatment. The peak serum creatinine level after showing renal dysfunction was 4.19 AE 1.49 mg/dl. Acute interstitial nephritis was confirmed by renal biopsy in 5 (33%) patients, while 6 patients (40%) were clinically diagnosed with acute interstitial nephritis based on the urine findings or other abnormal results. Steroids were administered to 9 (60%) cases for presumed acute interstitial nephritis. Renal function fully recovered in 12 (80%) patients. 3 patients (20%) showed further renal dysfunction despite stopping the anti-TB treatment and administering steroids. Rifampicin was a presumed drug causing renal dysfunction in 14 (93%) cases. Conclusions: Our results suggested that the renal dysfunction mostly occurred during intensive phase of standard anti-TB treatment. Rifampicin was a leading candidate of that. We found that the avoidance of rifampicin was generally effective for completing anti-TB treatment without relapsing renal dysfunction after temporarily discontinuing anti-TB therapy. Although it is controversial, we thought administration of steroids for short period is acceptable for suspected or confirmed acute interstitial nephritis cases if discontinuing anti-TB drugs did not sufficiently improve the renal function. Introduction: Pulmonary and pleural ectopic thyroid tissues are very rare and has never been described. This curious case highlights the approach to the diagnosis of pleural effusion, including imaging and invasive techniques to arrive at a correct diagnosis to guide proper management. Case Presentation: A 60/F was previously diagnosed to have multinodular toxic goiter, and underwent total thyroidectomy 16 years ago. Postoperatively, she was asymptomatic and biochemically euthyroid, with no maintenance medications. She was well until 1 year prior when she experienced recurrent pleural effusions on the left, relieved by repeated thoracentesis and workup revealed equivocal findings. She subsequently underwent tube thoracostomy. Chest CT scan revealed multiple pleuralbased masses and ultrasound-guided biopsy with immunohistochemical stain revealed benign ectopic thyroid tissues. Neck ultrasound also revealed left thyroid nodule which was follicular adenoma by biopsy. TB-PCR of the pleural fluid was positive and anti-TB medications were started. She eventually underwent talc pleurodesis and chest tube removal. However, on the 2nd week of admission she had hematochezia where a colonoscopy showed a large tubular adenoma obstructing the distal colon. A colectomy and resection was planned however she succumbed to an acute myocardial infarction during the 4th week of admission. Discussion: Presentation of ectopic thyroid tissues can range from asymptomatic to devastating with dyspnea and hemoptysis. It is postulated that they arise from an aberrancy in the embryogenesis of thyroid development. As predicted, the most common sites are those that involve the thyroid tract as it ascends from the primitive foregut. Our case is indeed a very rare case since the pleura and the thyroid gland are not related embryologically, and pleural effusions from ectopic thyroid tissue has not been reported in recent literature. Management of our case should have involved surgical resection of the pleural implants, together with radioiodine therapy to control symptoms. Isolates were susceptible only Ciprofloxacin and Amikacin. First Thorax CT scan showed extensive bronchiectasis, diffuse nodularity of the lungs, tree-in bud appearance. Methods: Based on these initial findings, Clarithromycin (1 Gr/day) and Amoxicillin/Clavulanic Acid (2 Gr/day) administered for seven days but resulted in increasing complaints with no clinical improvement. For parenteral antibiotic treatment hospital admission was recommended but she could't do it. Therefore Ciprofloxacin, Amikacin couldn't be administered that we preferred Gemifloxasin (320 mgr./day). Since Gemifloxasin could be taken daily and orally, therapy could be continued for 10 weeks. However, feeling better she refused further therapy and finalized Gemifloxasin intake after 10 weeks. Results: Treatment outcome was favorable; her symptoms mostly resolved in 3 weeks. Radiographyic findings improved slowlier. After 12 weeks Thorax CT scan were revealed significant changes. Conclusions: M.Abscessus Lung Disease may progress very slowly. Therefore, the treatment is very complex. The therapy aimed to improve the symptoms, radiographic regression and sputum conversion to negativity. Amikacin, clarithromycin, and cefoxitin were tested to be susceptible to M.Abscessus variants. These antibiotics had only a bacteriostatic effect against M.Abscessus within macrophages, that the refractoriness of invasive pulmonary infection to antibiotic therapy can be explained. Since fluoroquinolones can be administered daily and orally for a long period of time, so highly attractive in the therapy of M.Abscessus. Several patients being treated with M.Abscessus by the combination of fluoroquinolones and clarithromycin, however the activities are still unclear. M.Abscessus therapy yet couldn't been optimized by the regimen of the combination with Amikacin, Cefoxitin, Imipenem, Clarithromycin, and Fluoroquinolones. Still plenty of problems are to be solved. Background and Aims: M. tuberculosis (MTB) remains one of the most common causes of death among infectious pathogens. Rapid diagnosis and treatment of pulmonary tuberculosis is still a great challenge. The GeneXpert MTB/RIF assay is a novel integrated diagnostic system for rapid detection of MTB pathogen and rifampicin resistant strain. The objective of this study was to evaluate the diagnostic performance of sputum GeneXpert MTB/RIF for smear negative pulmonary TB in a high burden country as Thailand. Methods: Diagnostic test study of suspected TB patients who had negative two smear AFBresults at Srinagarind hospital between 2010 and 2014. Results: All of them had at least 2 negative sputum AFB staining results. 76 patients were diagnosed as smear negative pulmonary TB and 75 cases were not pulmonary TB. The sputum culture grew M. tuberculosis in 32 of 76 pulmonary TB patients. The sensitivity of GeneXpert MTB/RIF assay was 83.9% (95% CI, 66.3%-94.5%) and the specificity was 92.1% (95% CI, 83.6%-97%). The positive predictive value (PPV) and negative predictive value (NPV) were 81.3% (95% CI, 63.6%-92.8%) and 93.3% (95% CI, 85.1%-97.8%), respectively. The likelihood ratio positive (LR+) and likelihood ratio negative (LR-) were 10.6 (95% CI, 4.8-23.3) and 0.18 (95% CI 0.07-0.39), respectively. For 151 cases who suspected pulmonary TB, the concordance of these two tests, M.tuberculosis culture growth and GeneXpert MTB/RIF result, was 77.5% (κ = 0.46). The GeneXpert MTB/RIF assay detected 5 RIFresistant MTB sputum samples, but only 1 confirmed by drug susceptibility test (DST). Conclusions: In conclusion, GeneXpert MTB/RIF assay had high sensitivity and specificity for diagnosis smear negative pulmonary TB. The GeneXpert MTB/RIF assay was recommended for suspicious pulmonary TB cases, if two sputum AFB staining results were negative. The benefit of this assay was it could be reported quicker than culture result, and had more yield than culture for detection rifampicin resistant strain. Background and Aims: In the past, intrapleural administration of fibrinolytic agent has shown good outcomes for complicated pleural infection although contrary evidence are shown in various small studies. Nowadays, surgical interventions including thoracotomy and decortication have been advocated for fibrothorax. Here, we present a case of tuberculous fibrothorax that obviates the need for surgical referral and treated effectively via medical therapy. Case History: A 37-year-old male presented to us with shortness of breath, left sided pleuritic chest pain and 10 kg weight loss over two months. He had 5-day history of fever. Pleuroscopy was performed for large symptomatic left pleural effusion but the pleural drainage was hampered by the presence of multiple loculations separated by thick fibrin walls. Intrapleural fibrinolytic (streptokinase) was given. He was administered broad-spectrum intravenous antibiotic and anti-tuberculous agents, with continuous chest tube drainage for nearly a month. Subsequent pleuroscopy showed resolution of the fibrothorax. Conclusions: Streptokinase may be considered as a reasonable option in cases of pleural infection complicated by fibrothorax in medical facility with limited resources. Background and Aims: Tuberculosis (TB) remains one of the major concerns for people living with poverty. One of the therapeutic challenge is patient non-adherence to anti-tuberculosis treatment. Further antituberculosis drug resistance occurs due to newly acquired mutations from nonadherence to antituberculosis treatment. Aim of this study was to assess the determinants of non-adherence to antituberculosis treatment, including drop out and lost to follow up in pulmonary TB patients living with poverty in East Java, Indonesia. Methods: This is a cross-sectional study among 225 TB patients aged >18 years conducted on July-December 2015. Primary outcome was socioeconomic variables such as lack of money, lack of social support from family or community, and distance from treatment centre. Secondary outcome was individual behavioural variables such as fear of stigma, feeling better after few weeks of treatments, knowledge about TB treatment (duration, curability, and side effects), and alcohol or tobacco use. Results: A total of 89 (39.56%) TB patients experienced non-adherence treatment, including 42 (18.22%) cases loss to follow-up. Only 122 (49.78%) of patients took drugs under strict direct observation and were supervised by health care workers. Factor analyses suggested that patients who live further (>10 kms) from treatment centre [PR: 3.50, 95 % CI: 1.87-10.43 ] and less income ( 18 years and with no prior history of pulmonary tuberculosis subjected to 3 sputum smear microscopy. The percentage of positive smears, incremental yield of each sputum smear and the positivity rate of 2-smear combinations were analyzed. Results: The study shows that the 1st 2 sputum smears can detect majority of cases (N = 185), with the 3rd smear adding only a minimal diagnostic yield (N = 2). However, it is noted that the smear positivity rate increases in the succeeding sputum smear specimens with a comparable positivity rate in the 2nd (20.4%) and 3rd(20%) smears. Among 2-smear positive combinations, a significantly higher rate of smear positivity (2.8%) and a higher incremental increase of positivity rate (40%) is noted with the 2nd and 3rd specimens over the other combinations. Conclusions: A 3-sputum smear specimen in the case detection of pulmonary tuberculosis has non-negligible diagnostic yield in the succeeding specimens and a significantly higher rate of smear positivity is observed with 3 specimens over those with less. and get vaccine with TST <10 mm by 57.1% (48 subjects). Subjects who did not received vaccine with positive IGRA 19.05% (16 subjects) and who did not get vaccine with TST ≥10 mm by 13.1% (11 subjects). Subjects who did not get vaccine with negative IGRA 8.3% (7 subjects) and who did not get vaccine with TST results <10 mm by 13.1% (11 subjects). Agreement between IGRA and TST is sufficient (Kappa 0.32). Characteristics of the subjects are males 48.8% (41 subjects) and females 51.2% (43 subjects), the mean of age 38.06 years with risk factors that statistically significants are length of employment, BCG vaccination and age. The highest sensitivity and specificity of IGRA are 94.4% and 60.6% respectively Conclusions: Our study showed the comparison between IGRA and TST in healthcare workers in BBKPM Bandung, agreement between TST and IGRA is sufficient and there is a significant correlation between the positive test results and risk factors of length of employment, BCG vaccine and age. This study we recommend that an IGRA good to use as screening tests replace the TST. philippine heart center, pulmonary department, quezon city, Philippines, and 2 philippine heart center, Adult Pulmonary, Quezon City, Philippines Introduction: A pseudoaneurysmal dilatation of the branch of pulmonary artery called Rasmussen's aneurysm is a very rare sequalae of pulmonary tuberculosis Life threatening massive hemoptysis from the rupture of the aneurysm is an uncommon complication of cavitary tuberculosis. Case presentation: A 59 year old woman complained of massive hemoptysis that started a few hours prior to admission. She was a nonsmoker. On examination she was pale and diaphoretic; normotensive, tachycardic with a normal respiratory rate. Fine crackles on all lung fields noted during chest and lung examination. Her chest xray revealed pulmonary congestion. Antifibrinolytic agent was given intravenously. The condition of the patient resolved temporarily. On the 3rd hospital day, CTPA revealed saccular aneurysm (Rasmussen) in the segmental branch of the right pulmonary artery; measuring 0.6 x 0.7 cm supplying the medial segment of the right middle lobe, multiple pulmonary nodules due to an infectious process. On the 9th hospital day, massive hemoptysis recurred, approximately amounting to 1500 cc. Her blood pressure drop to palpatory 60 mmHg. She went into cardiac arrest subsequently patient expired. Discussion: Pulmonary tuberculosis results in the erosion of the adjacent structures in the lung. A tuberculous process that occurs near a vessel wall leads to thickened intima protrusion and an aneurysm results. Medical management can be employed if hemoptysis is minimal, however it is recommended that surgery should be performed in patients who had an episode of massive hemoptysis. Conclusion: Rasmussen's aneurysm is a rare tuberculous sequelae. Literatures report that the hemoptysis is usually massive and it entails the need for early and aggressive management. Background and Aims: Latent tuberculosis (LTBI) is defined as a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens without evidence of clinically manifested active tuberculosis (TB). Infection control in the high risk place such as dormitory is important for controlling TB transmission. The other factors like Household surveillance and contact tracing of TB is regarded as an essential measure to prevent further TB dissemination in community. This is a preliminary (cross sectional) study of contact investigation of a pulmonary TB patient in a college dormitory in Jakarta, Indonesia and have been approved by ethical committe faculty of medicine Universitas Indonesia. Methods: Fifty seven female students ages 19-21 years old whose living in the same dormitory with the index case TB patient acid fast bacilli positive for more than three months after been diagnosed. Subjects were interviewed regarding past and present TB history, followed by chest x ray, Xpert M.Tb RIF sputum and Interferon gamma release assay (IGRA) quantiferron test. LTBI is defined if IGRA test positive and the other tests were negative. Three subjects had been excluded due to lack of tool to perform IGRA. Results: Bacillus Calmette Guerin (BCG) were vaccinated in 83% subjects (45/54) and 5% (3/54) are present with TB-related symptoms but proven non TB at the moment. Four subjects (7%) without past and present TB history exhibit positive IGRA result and 1 of whom shows TBrelated radiological result. All subjects are showing negative Xpert M.tb RIF from their sputum examinations. Limitations of this study is unable to differentiate LTBI do to contact in dormitory or other contact. Conclusions: Contact investigation of the dormitory have able to indicate 7% subjects whose suggestive for LTBI. Recommendation for this study is to explore more about environment, nutrition, education and infection control. Background and Aims: Serial testing of interferon-gamma release assay (IGRA) shows conversion and reversion in health care workers. There are limited studies in the variance of IGRA results in close contacts of infectious tuberculosis (TB) patients. This study aimed to know variance of IGRA responses in serial testing. Methods: We prospectively followed up family and school contacts of infectious TB cases for 2 years or more after exposure. QuantiFERON Gold In-Tube Assay (QFT-GIT), and chest X-ray were followed up at initial, 3 -6 months (FU1), 1 year (FU2), and 2 years (FU3) after last exposure. Preventive treatment was recommended to IGRA positive responders. Results: A total of 3,088 close contacts with a mean age of 15.3 AE 2.4 years old were recruited from 117 index cases. Initial IGRA positivity was 11.5%. 2,104 contacts completed 3 follow up examination without preventive treatment. Among the 73 initial positive responders, 53 (72.6%) contacts were reverted at FU1. However, eight (15.1%) of them were converted again at FU2 and five (62.5%) contacts were reverted again at FU3. Overall positivity at FU1, FU2, and FU3 among the initial positive responders was 27.4%, 38.4%, and 32.9%. Among the 2,031 initial negative responders, 69 (3.4%) contacts were converted at FU1. However, 55 (80.0%) contacts were reverted at FU2 and five (9.1%) contacts were converted again at FU3. Follow up IGRA testing were poorly conducted to the contacts started preventive treatment. Three (25.0%) among 12 contacts who started preventive treatment because of initial positivityS or conversion at FU1 were reverted at FU2. Conclusions: Close contacts of infectious TB cases showed various conversion and reversion rates in the serial testing of IGRA. This study suggests that a simple dichotomous definition of IGRA negativity and positivity may not be suitable to diagnostic cut-off value in serial testing. Background and Aims: Given an advance in the detection tool of Mycobacterium tuberculosis (M.TB), it is expected that more patients have been confirmed with tuberculous pleurisy by microbiologic evidence than in the past. There are few studies to investigate clinical features according to the culture of TB in patients with TB pleurisy. Methods: From Jan. 2010 to Dec. 2014, medical records of adult patients who were diagnosed and treated with TB pleurisy were reviewed retrospectively at the Seoul St. Mary's hospital and the Bucheon St. Mary's hospital. Results: Among 343 patients with TB pleurisy, 119 patients (34.7%) were confirmed by a positive culture for M.TB. The positive group for M.TB culture showed young age and had more frequent autoimmune diseases, compared with the negative group. Regardless of the presence of M.TB in pleural specimens, sputum study for M.TB infection such as stain for acid fast bacilli, culture or PCR for M.TB, revealed positive results in half of the patients of the both groups (75/119 cases vs 107/224 cases). As for the analysis of pleural effusion, the positive group for M.TB had significantly lower level in percentage of lymphocytes and in glucose than the negative group. The cure and complete rate for the disease was 91.6% in the positive-culture group and 92.9% in the negative-culture group. There was little difference in the treatment response including relapse and survival between the two groups. Conclusions: These findings proved that with further improvement of diagnostic technology for M.TB, patients with TB pleurisy has showed more frequently microbiologic evidence unlike in the past. In addition, our study confirmed that the positive culture for M.TB was associated with lower lymphocytosis and glucose in the pleural fluid. However, the existence of the culture for M.TB had no influence on the treatment outcome. (2012) reports that 3,7% of the whole proportion of new TB cases in the world has multidrug resistance. Currently, Indonesia places second in rank for the number of TB cases in the world. The establishment of diagnosis by sputum culture and M. Tuberculosis resistance test take at least 6 to 8 weeks, resulting in the delayed MDR TB treatments commencement and an increased risk of infection spread. An Assessment tool that produces quicker diagnostic results is greatly needed. An elevated level of Interleukin 17 in MDR TB patients could be one measure of a new assessment tool for early detection of MDR TB. Methods: The study design is cross sectional. Sixty MDR TB sufferers who are seeking treatments at the MDR TB polyclinic in Dr. Hasan Sadikin hospital Bandung from periods July-December 2013. Results: The results for the level IL-17 range from 0,09 -34,40 pg/ml, with median value of 0,25 pg/ml. The average level of IL-17 in the MDR TB group is 1,74 pg/ml, while for non-MDR TB patients 0,25 pg/ml. There is a significant difference between the two group (p = 0,03). Conclusions: The conclusion of this study is that there is a significant difference between the IL-17 level in the MDR TB group than non-MDR TB group. Background and Aims: The aim of this paper is to present a case of a 59-year-old-male who came in due to difficulty of breathing, cough and a fluctuant mass on his right thigh, who was diagnosed with septicemic melioidosisbased on blood, sputum and wound cultures and who was also diagnosed with a pulmonary tuberculosis co-infection and was managed accordingly. In addition, this paper also strives to create awareness among local healthcare professionals about melioidosis and the possibility of co-infection with pulmonary tuberculosis in high risk patients. Methods: We are reporting a case of a 59-year old-male who lives in Bulacan, Philippines. He is a poultry raiser and a vegetable farmer, with 2 weeks history of right thigh abscess. He also complained of cough, fever, dyspnea and weight loss. Results: Our patient was initially diagnosed with a right thigh abscess, a community acquired pneumonia -moderate risk. A consideration of a concomitant pulmonary tuberculosis was also thought. B. pseudomallei was isolated in cultures of blood, sputum and wound, diagnosis of septicemicmelioidosis was entertained. Therapy for melioidosis was started for this patient. Despite antibiotics, the patient still was observed to be having low grade fever. Although the patient's sputum AFB result is negative, given the following risk factors of poorly controlled diabetic, a high index of suspicion for pulmonary tuberculosis co-infection is considered. Since the patient was not diagnosed or treated for tuberculosis earlier, he was empirically treated with quadruple fixed dose combination anti-koch's medications. Conclusions: All patients presenting with clinical features of tuberculosis, must be investigated and worked up to rule out melioidosis and possible co-infection with tuberculosis. Early diagnosis and treatment can reduce the risk of death caused by melioidosis. Melioidosis and pulmonary tuberculosis co-infection is extremely rare, awareness of its possibility of existence and occurrence should not deter clinicians in treating both disease entities. Background and Aims: Childhood tuberculosis has an increasing incidence worldwide. Its occurrence represents an important event indicating a recent transmission. The identification of a surrogate biomarker for treatment response and risk for poor outcome in tuberculosis will be a beneficial tool in the patient's management. Thus, a biomarker like high sensitivity C-reactive protein (hsCRP) was proposed to be a prognostic marker. Methods: Children diagnosed with tuberculosis based on the Philippine Pediatric Society and National Tuberculosis Program guidelines were included. Clinical data were reviewed and recorded. Blood samples were collected for serum hsCRP determination before the treatment and after the intensive phase. Data analysis was done using Stata SE version 12. Mean, standard deviation, frequency, percent distribution, paired T test and scatter plot were used. The level of significance was set at 0.05. Results: There were 40 subjects with pulmonary tuberculosis who participated. Twenty-three were male (57.5%) and 17 were female (42.5%). The age ranged from 1 to 18 years with a mean age of 8.6 + 5.5. Out of the 40 participants, 32 had completed the study. The analysis of data showed that the level of serum hsCRP after the intensive phase of treatment was significantly lower compared to the level before treatment (p value of 0.0002). On the other hand, body mass index, which is being used as one of the objective parameters of treatment response in children, demonstrated a statistically significant difference before and after the intensive phase (p value of 0.0007). HsCRP and BMI were indirectly correlated, however, it was statistically insignificant. Conclusions: This study has shown that there is a statistically significant lower serum hsCRP level after the intensive phase of treatment among pediatric patients with tuberculosis. It is the therefore concluded that hsCRP can be an additional parameter to evaluate treatment response as early as 2 months of treatment. Background and Aims: ADA in pleural effusion is known to be a useful tool to make diagnosis of tuberculous pleurisy. Our hospital has Tuberculosis Control Unit and we have a little more chances to see the patients with tuberculous infection. However, we still experience patients with high level ADA in pleural effusion but without tuberculous infection. The aim of this study is to examine the background of the patients with high ADA pleural effusion and the characteristics of the nature of their pleural effusion. Methods: Patients who received pleurocentesis in our hospital in 2015 were enrolled. The clinical charts of the patients whose ADA in pleural effusion was more than 40 IU/L were reviewed. Results: 19 patients out of 93 patients who received pleurocentesis have more than 40 IU/L ADA in pleural effusion. All of the samples met the light's criteria of exudative pleural effusion. Average age was 72 years old and 11 men were included in the 19 patients. Underlying disease were tuberculosis pleurisy (42%), malignant disease (21%), pneumonia associated pleural effusion (16%), Rheumatoid Arthritis (5%) and undiagnosed (16%). There seems no difference in the nature of pleural effusion among the underlying diseases except for pneumonia associated pleural effusion of which effusion showed high LDH, high polynuclear leukocyte cell, low pH, and low glucose. Conclusions: The percentage of tuberculosis pleurisy was only 44 % and there was a variety of underlying disease which caused high ADA in pleural effusion. ADA in pleural effusion is a useful tool for the diagnosis of tuberculosis pleurisy, but detailed evaluation was necessary for accurate diagnosis. Background and Aims: Tuberculosis (TB) remains a major public health problem in Georgia with estimated incidence and prevalence of 106 and 145 per 100 000 population respectively. Little evidence exists globally on the burden of hospital acquired TB infection among health care workers (HCWs) and impact of different infection control (IC) measures in reducing risk of nosocomially acquired tuberculosis. Methods: We evaluated performance of commercially available equipment "Plasma Cluster Ion Generator" (Sharp Corporation) in reduction of latent tuberculosis infection (LTBI) risk, among HCWs at specialized TB Hospital, National Center for Tuberculosis and Lung Diseases (NCTLD). Plasma Cluster units were placed per manufacturers' recommendations at two out of four therapeutic departments with identical administrative, engineering and personal protective IC measures. Baseline and six month apart, two follow-up testing with QuantiFERON-TB Gold In-Tube (QFT-G, Quest Diagnostics) was performed to compare risk of tuberculosis infection among Plasma Cluster exposed and non-exposed groups. Results: From total 100 HCWs screened for LTBI at baseline, 42 (42%) were from exposed, 46 (46%) from non-exposed and 12 with mixed place of work (excluded from further analysis) groups. Out of 32 QFT negative at baseline HCW 10 (90, 9%) remained negative and 1 (9, 1%) became positive in exposed group and 15 (71%) remained negative and 6 (28%) became positive in non-exposed group with QFT follow-up tasting. Based on QFT conversion data, subjects within no plasma cluster settings showed 4 times greater risk of acquiring tuberculosis infection compared to subjects within plasma cluster settings. (OR = 4, 95% CI = 0.36-102, Fisher exact p-value = 0.21). Conclusions: Plasma Cluster Ion generator technology has shown good performance and feasibility of use at tuberculosis hospital and has substantially decreased the risk of Tuberculosis Infection among HCWs. Background and Aims: Advance lung cancer usually metastasize to the adrenal glands, bone, liver or brain. Upper gastrointestinal haemorrhage (UGIH) as a result of gastrointestinal metastases is a rare initial presentation. We present two patients who had initial presentation of malaena secondary to duodenal metastasis of primary lung cancer. Methods: The first patient is a 64-year-old man. He is smoker and presents with melaena, hemoptysis, lethargy and lost of weight for two months duration. Oesophagogastroduodenoscopy (OGDS) shows multiple polypoidal mass with Forrest IIc-III ulcers at the duodenum. Histopathological examination and Immunohistochemical staining confirms primary lung adenocarcinoma. Computer-tomography thorax reveals a right upper lobe mass measuring 3.0x3.5x4.0 cm with liver, mesenteric and contralateral lung metastases. The second patient is a 73-year-old lady. She is a non-smoker who came with recurrent episodes of melaena, symptoms of anemia and weight loss for three months duration. OGDS shows presence of large circumferential mass measuring 2.5 cm with ulcerated base at third part of duodenum. Histopathological examination confirms duodenal metastasis secondary to poorly differentiated adenocarcinoma. Subsequent computertomography thorax guided biopsy confirms primary lung adenocarcinoma. Results: Lung adenocarcinoma with upper gastrointestinal haemorrhage due to duodenal metastasis is uncommon. Treatment modalities available include combination of surgery or endoscopic resection with neo-adjuvant chemotherapy. Conclusions: Upper gastrointestinal haemorrhage as the initial presentation of distant metastasis from lung adenocarcinoma is uncommon. It should be considered by clinicians when managing these group of patients. Background and Aims: Synovial sarcoma (SS) is a destructive, atypical tumour originating from mesenchymal tissue. It accounts for approximately 5-10% of all soft tissue sarcomas, and is more infrequent as a lung primary as well as younger patients. We report a rare case of primary endotracheal synovial sarcoma in a 53-year-old man presenting with asthma-like symptoms who responded well to radiotherapy. Methods: A 53-year-old man presented with an 8-month history of intermittent shortness of breath. There was no significant family history of asthma or atopy. Minimal crepitation on lungs auscultation. There was evidence of airway obstruction from the spirometry of FEV 1 0.66 L FVC 1.73 L FEV1/FVC 38% with reversibility of 23%. A high-resolution computed tomography (HRCT) of the thorax however revealed a pedunculated endotracheal mass confirmed on bronchoscopy. The histopathology examination showed epithelioid morphology and the immunohistochemical studies showed tumour cells diffusely positive to CD99 and focally positive to cytokeratin and S100 which is consistent with the diagnosis of synovial sarcoma. The patient underwent radiotherapy treatment for a total of 8 weeks. Repeated bronchoscopy and CT thorax showed 85% reduction of the tumour size. A repeated spirometry also showed improvement in the level of airway obstruction with FEV 1 2.31 L FVC 2.88 L FEV 1 /FVC 80% post treatment. He is currently well and under our clinic follow-up for 6 months Conclusions: To our knowledge this is the 4th reported case of synovial sarcoma of the endobronchial tree. The mainstay of treatment for soft tissue sarcoma is surgical removal of the tumour. Our patient showed a marked improvement in both symptoms and size of the lesion with radiotherapy treatment Background and Aims: The relationship between the pharmacokinetics and effects of gefitinib in patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC) is unknown. In this study, we examined the correlation between gefitinib plasma concentration and progression-free survival (PFS) in patients with two common types of EGFR mutations: a deletion in exon 19 and point mutations in exon 21 L858R. Methods: This retrospective analysis examined 40 patients who were administered 250 mg of gefitinib daily. All patients were diagnosed with and treated for advanced (clinical stage IIIB or V) non-small cell lung carcinoma with sensitive EGFR mutations between January 2011 and November 2013 at Akita University Hospital, Akita, Japan. On day 14 after treatment initiation, plasma samples were collected prior to the first administration of gefitinib. Plasma concentrations of gefitinib were measured by high-performance liquid chromatography (HPLC). The 40 patients were divided into four groups by trough plasma concentration (high or low) and mutation type (exon 19 deletions or exon 21 L858R point mutations). PFS, response rate, and toxic effects were analyzed in all four groups. Results: After excluding 5 patients, the remaining 35 were successfully analyzed. There was no significant difference in PFS between the exon 19 deletion and exon 21 L858R point mutation groups (median survival: 17.0 v. 10.5 months, P = 0.1768 ). For the patients with exon 19 deletions, there was no significant difference in PFS between the high and low plasma concentration groups (median survival: 12.0 vs. 17.0 months, P = 0.9548). In contrast, the PFS was significantly prolonged for patients with exon 21 point mutations and high vs. low concentrations of gefitinib (median survival: 16.0 vs. 8.0 months, P < 0.05). Conclusions: The results suggest that high plasma concentration of gefitinib in patients with EGFR Exon 21 L858R point mutations is compared to Low plasma Concentration, PFS was prolonged. Background and Aims: Malignant peripheral nerve sheath tumour (MPNST) is a rare soft tissue malignancy occurring in various anatomical sites. Intrapulmonary cases are extremely rare. Most cases have poor prognosis and often need aggressive surgical intervention. Methods: The case was a 33-year-old non-smoker woman with a giant intrapulmonary MPNST. The patient came with right chest pain, dyspepsia syndrome and diagnosed with tuberculosis. Abdominal ultrasonography and CT scan with contrast showed a large space-occupying lesion. Open biopsy and pathology anatomy examination revealed the tip of mass from thorax with low grade sarcoma/MPNST grade 1. She was examined thoracic CT with contrast and suggested to have surgical debulking thoracotomy, but she refused. A year later, the patient came with severe right chest pain. The thoracic CT scan revealed a giant solid mass (12.8 x 11.1 x 13 cm) at the levels of 7 th , 8 th , 9 th , and 10 th right lung segments. Surgical debulking thoracotomy was the main treatment. Histopathologycal and immunohistochemical examinations confirmed that the patient had giant intrapulmonary MPNST with low proliferation rate. Almost a year after surgery, the patient was getting better. Results: MPNST is less sensitive to radiotherapy and chemotherapy. Surgical debulking thoracotomy is the main treatment. Appropriate diagnosis and treatment should be provided earlier for better outcomes. Background and Aims: Cancer cachexia affects up to 80% of patients with advanced cancers and accounts for nearly 30% of cancer-related deaths. Despite recent advances in understanding the pathological mechanisms of cancer cachexia, few therapeutic options are currently available. Ghrelin, an endogenous ligand for the growth hormone secretagogue receptor (GHSR), is produced in the stomach, suppresses inflammation, prevents muscle catabolism and stimulates food intake through activation of NPY/ AgRP signal in hypothalamus. We investigated the expression of energy homeostasis related molecules in stomach and hypothalamus and the pharmacological potential of ghrelin in the treatment of cancer cachexia. Methods: We generated a postnatally, and bronchioalveoler epitheliumspecifically Pten-deleted mouse strain (Pten-KO). We administered urethane intraperitoneally to the 8-weeks-old Pten-KO and wild type mice (Pten-WT). Ghrelin or PBS was given to the mice daily for four weeks beginning at five months after urethane injection, which corresponded to the time point of lung adenocarcinoma formation. Measurement of ghrelin levels in mice and lung cancer patients was analyzed by ELISA. The expression levels of energy homeostasis related molecules in hypothalamus were examined by quantitative real-time PCR. Results: All of the Pten-KO mice developed lung adenocarcinoma. The plasma ghrelin levels of the Pten-KO mice and the lung cancer patients undergoing chemotherapy were significantly lower than Pten-WT mice and healthy volunteers, respectively. Ghrelin-treated Pten-KO mice had smaller reductions in food intake, body weight, skeletal muscle mass and intraabdominal fat weight than PBS-treated Pten-KO mice. Ghrelin treatment increased the expression levels of NPY and AgRP mRNA. In addition, ghrelin restored the increased levels of IL-6, TNF-α, proopiomelanocortin (POMC) and cocaine and amphetamine regulated transcript (CART) mRNA in hypothalamus of Pten-KO mice. Conclusions: The pleiotropic effects of ghrelin through the activating the NPY/AgRP signal and suppression of cytokine levels in hypothalamus may be an attractive therapeutic target in the patients with cancer cachexia. Background and Aims: Smoking is the leading cause of lung cancer and spontaneous pneumothorax. For smokers, surgical hospitalization is likely to be a good motivator to quit smoking. Methods: Data was collected from respiratory surgery patients between April 2009 to June 2015.They were; primary lung cancer(P-group) -160 cases, metastatic lung cancer(M-group) -54 cases, and spontaneous pneumothorax (S-group) -142 cases. Smoking history (smoker/nonsmoker or never-smoker, number of cigarettes smoked per day, number of years smoking, Brinkman Index(BI).Nicotine dependence test (TDS) was enforced in some cases) was checked in each case at before hospitalization or at hospitalization. The main outcome is set in the smoking status 1) at pre-hospitalization, 2) at discharge, 3) at one month after discharge and 4) three months after discharge. Patients who were smoking until just before the operation were specifically given attention to see whether the post-operative non-smoking instructions had become a motivation to quit. Results: Patient with smoking history was 115 cases in P-group(72%), 26 cases in M-group(48%), 142 cases in S-group(56%). In the P-group, BI average was 941, TDS average was 6.7. Patients who smoked until just before operation was 36 cases in P-group (23%), 5 cases in M-group (9%), 53 cases in S-group (37%). Non-smoking achievement rate by post-operative instruction at post-operative three months was 78% in Pgroup, 100% in M-group, 77% in S-group. Conclusions: More than 70% of patients achieved 3-months nonsmoking status after undergoing surgery and were given post-operative nonsmoking instructions. This suggests that hospitalization for respiratory surgery can become a motivator for smokers to quit the habit. Introduction: We herein report a case of penile Mondor's disease as a rare presentation of lung adenocarcinoma complicated with Trousseau's syndrome. Case presentation: A 45-year-old man presented to our hospital with non-productive cough and rash on both lower legs for one month. Two months before, he recognized a funicular palpable induration on his penile dorsal surface. Color doppler sonography showed no blood flow signal in the superficial dorsal penile vein, and also superficial leg veins. Computed tomography and 18 F-FDG PET revealed a solitary pulmonary nodule in the left upper lobe, multiple lymphadenopathies, and multiple hepatic masses. A transbronchial biopsy of the pulmonary nodule revealed adenocarcinoma with epidermal growth factor receptor (EGFR) gene mutation (deletion in exon 19). Finally, the patient was diagnosed with stage IV adenocarcinoma complicated with Trousseau's syndrome. Afatinib and edoxaban was started, which was temporarily effective. However, multiple cerebral infarctions from nonbacterial thrombotic endocarditis occurred to him, and edoxaban was changed to heparin. After administration of heparin, there was no recurrence of thrombosis. Discussion: Penile Mondor's disease (superficial thrombophlebitis of the dorsal vein of the penis) is a rare clinical diagnosis, and to our knowledge, this is the first case report of this condition associated with lung cancer. The risk of venous thrombosis in lung cancer patients is increased 20-fold compared to the general population. A retrospective study reported that the prevalence of non-small cell lung cancer patients with migratory superficial thrombophlebitis was 7%. Heparin is considered to be the firstchoice agent for controlling thrombosis associated with Trousseau's syndrome. Conclusions: This patient's presentation was unique in that Trousseau's syndrome caused penile Mondor's disease as the primary presentation. This case highlights the importance of including Trousseau's syndrome as the etiology of penile Mondor's disease. Background and Aims: Most of lung cancer patients have diagnosed in advanced stage. Most reasons for the delay of the diagnosis, might be from patient and/or health system. Currently, in Indonesia has National Health Insurance System (Jaminan Kesehatan Nasional). That situation made an increasing numbers of patient who come to referral hospital. In Persahabatan Hospital-the National Referral for Respiratory Diseases, the maximum time interval for lung cancer diagnosis was set not more than two weeks, however several cases were delayed. We had been conducting a study to evaluate time diagnosis time for lung cancer. Methods: We performed a simple observational study in Persahabatan Hospital Jakarta in January 2016. Fifty new patients was recruited in this study. We evaluated how long time was needed from the first visit until the initial diagnosis by histopatology obtained. We also evaluated the factors that have correlated with procedure diagnosis. Results: Fifty patients were enrolled in this study. Thirty five of fifty (70. %) were male and 12 of 50 (30%) were female. The median age were 58 years old with range 31 to 81 years old. Data have shown that 25 of 50 (50%) patient were diagnosed under target time (2 weeks) but 25 of 50 (50%) had diagnostic time more than 2 weeks. Diagnostic delay was correlated with: early stage of the diseases, poor performance status, respiratory distress. Conclusions: Stage and performance status at initial presentation, respiratory distress were associated with diagnosis delay in lung cancer in our hospital Background and Aims: The new targeted therapy of EGFR-TKi has been recommended as first-line therapy for patients with NSCLCC nonsquamous with mutated EGFR. There are no data about the efficacy and toxicity of the new targeted therapy of EGFR-TKi in NSCLC nonsquamous patients with mutated EGFR compared with chemotradiotherapy in wild type patients at Persahabatan Hospital, Jakarta. Methods: The design of study were retrospective cohort through medical records of NSCLC non-squamous patients in the Department of Pulmonology and Respiratory Persahabatan Hospital in January 2010 to July 2014. The sampling technique was consecutive. There were 61 patients consisted of 31 patients with NSCLC non-squamous with mutated EGFR treated the new targeted therapy of EGFR-TKi and 30 patients with EGFR wild type treated with chemoradiotherapy. Results: The characteristics of NSCLC non-squamous patients with mutated EGFR were mostly non-smokers, with equal proportion of exon 19 insertion/deletion and exon 21 codon L858R mutation, having 1-year survival 41,9%, and mean time to progression (TTP) was 284 days. Patients with wild-type EGFR are more dominant in males, smokers, 1year survival 33,3% and mean TTP was 210 days and overall survival was 293 days. The independent t test showed a significant relationship between the new targeted therapy with EGFR-TKi and TTP (p = 0.028). The most common adverse events in the EGFR-TKi group are nausea and vomitus 96,8%), diarrhea (16,2%), alopecia (3,2%) and rash (12,9%) and in the chemotherapy group, anemia (13,3%), leucopenia (6,7%) and thrombocytopenia (3,3%) . Conclusions: The EFGR-TKi treatment in patients who were preselected on the basis of EGFR mutations improved TTP with acceptable toxicity. Background and Aims: Management for lung cancer is a multimodalities therapy, such as surgery, chemotherapy, radiotherapy and targeted therapy. Tyrosine kinase inhibitor was indicated for lung adenocarcinoma with EGFR mutation. We evaluated the efficacy (Time-to-progression (TTP) and survival) of combination gefitinib and radiotherapy for lung adenocarcinoma with EGFR mutation. Methods: Eight patients were evaluated for this ongoing study. They were 6 of 8 (75 %) male and 2 of 8 (25 %) female, all of female patients were non-smoking. They have had 2 of 8 (25%) mutations are exon 19 deletions and 6 of 8 (75 %) exon 21 L858R point mutations. Results: Gefitinib have given in range 9.28 to 96,85 weeks and dose radiation have given in range 30 to 60 Gy. Data have shown that the median TTP were 50.57 weeks with range 9.28 to 96.85 weeks. The median overall survival were 36.58 with range 13.70 to 107.42 weeks. One female still alive, she treated chemotherapy after progresive diseases. In others hand we have no find severe toxicities of gefitinib. Conclusions: The Efficacy of combination gefitinib with radiaotherapy were similiar with median survival of advanced stage of lung cancer. Background and Aims: Lung cancer is the third most common cancer reported in Malaysia. However, there is paucity of data that look at the novel profiling of EGFR positive mutation lung adenocarcinoma patients. In this analysis, we sought to look for specific parameters that can be used to profile our EGFR positive mutation lung adenocarcinoma patients in Malaysian population. Methods: Dual-centre, prospective analysis of the baseline and subsequent visits of patients who attended UiTM Selayang and UiTM Sungai Buloh Respiratory clinic from 2014 till 2016. Besides clinical assessments, patients were given appropriate treatment. Patients' information and clinical data were obtained from UiTM Clinic online system and analysed via Statistical Package for the Social Sciences (SPSS) software for statistical analysis. Results: A total of 9 EGFR positive lung Adenocarcinoma (AC) patients (33.3% Male, 66.7% Female) were recruited. 56% aged <60 y.o (n = 5). 77.8% were Malays (n = 7). 77.8% were non-smokers (n = 7). 44.4% were diagnosed via CT guided biopsy (n = 4). Mutations detected are deletions in exon 19 and 21. All patients presented with Stage IV disease, in ECOG 1, had co-morbids, had cough, had normal BMI, had no family history of cancer, had normal albumin level, had positive TTF-1 in IHC and had opted for chemotherapy. Conclusions: Our findings are in-line with previous findings, in which majority of our EGFR positive Lung AC patients were female non-smokers. New findings are:patients are getting younger, had normal BMI, good ECOG, good nutrition status and they're not cachectic nor malnourished. These findings can be explained by the advancement of our technology that we're now able to detect the cancer earlier, before the patient progresses into malnourished state, and become severely symptomatic. This study is still in its very early phase in which there's no statistically significant data yielded at the very moment. More significant data are anticipated to follow in the future. Background and Aims: Epidermal growth factor receptor (EGFR) mutations are predictive marker of EGFR-tyrosine kinase inhibitor (TKI) therapy. We compared the sensitivity of EGFR mutation detection techniques between matched tumor tissue and peripheral blood sample in patients with lung adenocarcinoma. Methods: We collected the paired samples from plasma and paraffinembedded tumor tissue in 202 patients before EGFR-TKIs. DNA extraction was performed using the QIAamp MinElute virus spin kit and EGFR mutation analysis was done by two detection methods. One is the PNA-Clamp TM which is the PNA-based PCR clamping that selectively amplifies only the mutated target DNA sequence as minor portion in mixture with the major wild type DNA sequences. The other is the PANAMutyper TM EGFR kit, which use PNA clamping-assisted fluorescence melting curve analysis to perform mutation detection and genotyping. Background and Aims: After failure of epidermal growth factor receptortyrosine kinase inhibitor (EGFR-TKI), re-biopsy may be helpful to understand resistance mechanism and guide further treatment decision. However, re-biopsy is still challenging due to several hurdles, such as tissue availability, procedural feasibility, and limited new drugs. The aim of this study was to assess the feasibility of re-biopsy in advanced non-small cell lung cancer (NSCLC) in a real-world setting. Methods: We retrospectively reviewed the clinical and pathologic data of advanced NSCLC patients who had disease progression after previous EGFR-TKI at single institution between January 2015 and February 2016. Results: Ninety one patients had disease progression after using EGFR-TKI. Among them, thirty three patients (36.3%) underwent re-biopsy. The histological samples were obtained from surgery (3 cases), bronchoscopy (9 cases), CT-guided trans-thoracic needle biopsy (6 cases), and lymph node excision biopsy (4 cases). The cytological samples were obtained from thoracentesis (6 cases), pericardiocentesis (3 cases) and spinal tapping (1 cases). Only one patient didn't get malignant cell. Three patients experienced a pneumothorax, however only one patient required closed thoracostomy. After re-biopsy, 27 patients were performed EGFR mutation test. Among 21 patients who had active mutation, the initial mutation was again found in 9 cases (42.9%) while the T790M mutation was found in 6 cases (28.6%). In 4 cases the initial EGFR mutation was no longer found. The patients who had re-biopsy were younger (61.2 AE 9.7 vs 66.1 AE 10.8 p = 0.03) and longer response duration (429 AE 383 vs 265 AE 284 p = 0.022) than the patients who didn't Conclusions: Re-biopsy in advanced NSCLC is feasible in the real practice especially in younger patient and patients with longer response duration of EGFR-TKI. Background and Aims: Determining survival prognosis and defining the appropriate therapy in patients with lung cancer is challenging, as the majority of patients are diagnosed at a later cancer stage. The objective of this study was to investigate the effect of the different treatment groups on survival in Malaysian patients living with end stage non-small cell lung cancer (NSCLC). Methods: In this retrospective study, the medical records of 254 NSCLC patients (2009 254 NSCLC patients ( to 2012 were reviewed at Hospital Kuala Lumpur, Malaysia. The data were extracted for relevant information on the self-designed data abstraction forms. Results: In treatment groups, 200 cases (163 cases on chemotherapy and 37 cases on radiotherapy) were reviewed, whereas 27 cases were included in no treatment group. From all the reviewed cases, only 38.7% censored cases (i.e., alive) were found under chemotherapy. Conversely, none of the alive cases was found under radiotherapy and no treatment group. The estimated mean time until event (death) occurred was 700.82 days for chemotherapy, 168.45 days for radiotherapy and 62.81 days for no treatment group.The overall mean survival time was 521.5 days, with standard error of 47.89 days. The median survival time between treatment and death was 409, 78 and 49 days, for chemotherapy, radiotherapy and no treatment group, respectively. The comparison test results of the survival time was statistically significant (Chi-Square = 156.34, P = 0.000) among different groups. The findings of multivariate analysis while keeping the no treatment group as a reference suggested that the death proportion (hazard) for patients undergoing chemotherapy was 0.008 times or 91.2% lower and for those undergoing radiotherapy was 0.360 times or 64 % lower than the patients in the no treatment group. Conclusions: Results indicated an improved survival in patients undergoing chemotherapy or radiotherapy when compared to the patients with no treatment at the end stage disease. Background and Aims: There is a subclinical activation of coagulation and fibrinolysis system in lung cancer. Alterations in hemostatic system are seen frequently in lung cancer correlated with the prognosis of disease. In oncology practice, the use of tumor markers may be helpful in the diagnosis and pathologic classification of tumors. Tumor markers may reflect both, stage of the disease and prognosis. The aim of this research is to see the relationship of this parameter in chemoterapy patient of lung cancer. Methods: We rectropectively studied 41 lung cancer patients underwent chemotherapy in Haji Adam Malik General Hospital from January 2015 to march 2016. We measured serum level of Hemostatic parameter (PT 10-15 s, INR 0.8-1.2, APTT 21-45 s, TT <3 s from control, D-dimer < 500 ng/ml) and tumor marker (CEA 5 ng/ml, Cifra21-1 3,2 ng/ml, NSE 12,5 ng/ml) before the 1 st cycle of chemotherapy and after 4 th or 6 th cycle of chemotherapy. Results: From 41 patients we found that serum level of hemostatic parameter were not significantly correlated with serum level of tumor marker. PT (R = 0.038),INR (R = 0.041),APTT (R = 0.135), TT (R = 0.106), D-dimer (R = 0.011) with sig F change not significant (>0.500). Conclusions: There were not significant correlation of hemostatic parameter and tumor marker in patient underwent chemotherapy. But, further study and longer follow-up period were needed to make better conclusion. Methods: A 36-year-old man without any past medical history presented with dry cough and occasional wheezing for 3 years. He was treated as allergic rhinitis and gastroesophageal reflux disease but the symptoms did not improve. He came to Siriraj hospital due to persistent cough and non massive hemoptysis for 3 days. Physical examination revealed rhonchi at lower part of left lung. A chest radiograph did not demonstrated any abnormality. Computed tomography of the chest showed an enhancing mass protruding into left main bronchus 2.1x2.5 cm in size. Bronchoscopic finding demonstrated endobronchial mass at left main bronchus. Tissue biopsy was compatible with MEC. Patient underwent left lower lung sleeve lobectomy and histopathological examination revealed an intermediate-grade MEC with tumor-free margins and no lymph node metastases. The postoperative course was good without any sign of tumor recurrence and no adjuvant treatment was given. Results: MEC of the lung is a rare malignancy and usually arise in mainstem bronchi. The low-grade tumors can have a long natural history and rarely metastases, while the high-grade tumors can be very aggressive and prone to local invasion and early metastasis. Radical surgery with lymph node dissection is the treatment of choice for MEC. Patients with low or intermediate grade tumors can be expected to be cured following complete resection. In this patient, adjuvant therapy is not indicated. Objectives: To compare the clinical characteristics and consequences of uncommon and common EGFR mutations in advanced stage adenocarcinoma of the lung. Methods: An historical cohort study was conducted in Songklanagarind Hospital from June 2014 to December 2015. Patients with pathologically confirmed advanced stage lung adenocarcinoma who had positive EGFR mutations and treated at Songklanagarind Hospital were included. The clinical characteristics and outcomes with follow-up data that included overall survival and response to first-line treatment were analyzed for comparative purposes between the two groups of uncommon and common EGFR mutations. Results: Ninety patients were eligible for analysis. Common and uncommon mutations were confirmed in 79 (82%) and 11 patients (12%), respectively. No baseline clinical characteristics (i.e. mean age, gender, smoking history, performance status) were different between the groups. Patients with uncommon EGFR mutations were associated with significantly shorter survival (8 months) than patients with common EGFR mutations (22 months) (p = 0.0029). Moreover, response to first-line treatment in patients with uncommon EGFR mutations was significantly less than common EGFR mutations (9.1% versus 58.2%, p = 0.002). Conclusions: No differences in the clinical characteristics between uncommon versus common EGFR mutations were noted in advanced stage adenocarcinoma lung patients. However, patients with uncommon EGFR mutations were associated with significantly shorter survival and decreased response to first-line treatment compared with common EGFR mutations. Background and Aims: pPNETs are small-blue-round-cell malignancies of neuroectodermal origin, considered a member of the Ewing/PNET family of tumors and predominantly arising from the soft tissues and the bones. In the thoracic region, these tumors are more commonly seen originating from the chest wall ("Askintumor"). Pulmonary pPNETs are highly malignant with poor prognosis and extremely rare(<20 cases described in English literature). Literature review shows a male predominance with mean age of 28.2(8-56) years. Tumors are described as large, arising from peripheral parenchyma with cough, fever, dyspnea and chest pain being presenting symptoms. Differential diagnosis of thoracic pPNET includes small cell carcinoma and other small round-cell tumors. Histochemical and immunohistochemical studies are performed to confirm the diagnosis with CD99 positivity suggesting pPNETs. pPNETs are also characterized by presence of reciprocal translocation t(11 ;22)(q24 ;q12) in cytogenetic studies. The treatment of choice is combinations of radical surgical resection, neoadjuvant and adjuvant chemotherapy, and irradiation In this case-report, we describe pPNET of lung in a 5-year-old girl, who had rapid progression of the disease and lethal outcome Methods: Case: A 5-year-old female child was referred because of dyspnea, fever and cough. Chest radiograph showed right hemithorax opacity. Computed-tomographic scan showed a well-defined heterogeneously enhancing mass lesion measuring 11.1× 8.1 cm with no lymphadenopathy or effusion. Histochemical studies following ultrasound guided transthoracic biopsy showed small, round tumor cells arranged in sheets with high nucleocytoplasmic ratio on background of necrotic debris, suggestive of Malignant Round Cell tumor. Results: Immunohistochemistry showed CD99, vimentin positivity confirming diagnosis as pPNET of lung. Surgery along with chemoradiootherapy was planned but patient died before initiation. Conclusions: Normal 0 false false false EN-US JA X-NONE • Immunohistochemistry helps tremendously in differential diagnosis of small round cell tumor of lung facilitating early management. • Pulmonary PNETs are aggressive neoplasms with high mortality rate. The treatment of choice is early surgical removal with intensive chemoradiotherapy but prognosis remains dismal. Background and Aims: Epidermal growth factor receptor (EGFR) mutation T790M is the most common mechanism of acquired resistance to EGFR-tyrosine kinase inhibitor (TKI). In this study, we analyzed the T790M status and clinical course of patients who underwent rebiopsies after acquiring resistance to EGFR-TKI. Methods: We investigated 16 patients harboring EGFR-sensitive mutations to examine the emergence of T790M after TKI failure. The peptide nucleic acid-locked nucleic acid polymerase chain reaction clamp method was used for EGFR mutational analyses. Patient characteristics (age, gender, histology, clinical stage, EGFR mutation site, progression-free survival with initial TKI, and rebiopsy site) and genetic changes were analyzed. Results: Of the 16 patients, 12 were male and 4 were female (median age, 70 years). All patients had activating EGFR mutations; six (37%) had the exon 19 deletion mutation and 10 (63%) had the exon 21 point mutation L858R. After developing resistance to EGFR-TKI, T790M was identified in six (37%) of 13 lesions (3 lung tissues, 8 pleural effusions, and 2 pericardial effusions), but it was not detected in the central nervous system (3 cerebrospinal fluids). In a T790M-positive patient who underwent another biopsy after the failure of systemic chemotherapy, the T790M status had changed from positive to negative. From this result, we were able to select EGFR-TKI rechallenge as a treatment for the patient. Although invasive biopsies have associated risks, we did not encounter any significant complication in this series of patients. Conclusions: Tumor rebiopsies should be performed after the development of resistance to EGFR-TKI to identify the best treatment options for patients. Background and Aims: We prospectively evaluated the efficacy and toxicity of non-platinum triplet regimen, which consist of paclitaxel, irinotecan, and bevacizumab for patients with advanced non-small cell lung cancer (NSCLC) expected to be platinum resistant. Methods: All patients were diagnosed with NSCLC using endobronchial ultrasonography with a guide sheath (EBUS-GS) system. We defined the EBUS-GS as a core biopsy. RNA was immediately isolated from this unfixed biopsy specimens, and quantitative real-time reverse transcriptase PCR assays were performed to determine the excision repair crosscomplementing 1 (ERCC1) mRNA expression. Patients with advanced, untreated NSCLC showing high ERCC1 levels (ΔCt≧6.5) were entered the phase II trial of the non-platinum triplet regimen. Paclitaxel of 180 mg/ m2 on day 1, irinotecan of 50 mg/m2 on day 1 and 8, and bevacizumab of 15 mg/kg on day 1 were administered every 4 weeks. Primary end point was the objective response rate (ORR), assuming 30% for a standard therapy and 60% for a target therapy (α = 0.05, β = 0.1), and the estimated required total number of patients was 28 by Simon's Optimal Twostage Design. Results: Total 141 untreated patients received EBUS-GS and were evaluated the expression of ERCC1, and 30 patients were entered in this trial. The ORR was 66.7% ]. Median progression-free survival was 174 days. Grade 4 thrombosis occurred one patient, but other toxicities were mild. Fifty-three patients were treated with platinumcontaining regimens and 22 patients were responded (ORR was 41.5% [95% CI: 28.1-55.9]). Twenty-three of these patients were high ERCC1 levels and 6 patients were responded, and 30 patients were low ERCC1 levels and 16 patients were responded (p = 0.0053, by Fisher's exact test). Conclusions: The triplet combination of paclitaxel, irinotecan and bevacizumab might be effective for patients with advanced, untreated NSCLC overexpressing ERCC1. ERCC1 mRNA levels extracted from unfixed lung biopsy specimens obtained by EBUS-GS also might be a predictive factor for platinum-containing regimens. Background and Aims: Large scale health data collections have attracted much recent interest. Administrative databases have provided source data for studies in lung cancer of survival, practice patterns, multidisciplinary care and adherence to guidelines. In Australia most routinely collected data goes into government-run repositories not generally available to clinicians, the data are often several years old and not tailored to the needs of clinicians. Rationale: This descriptive study has three main objectives: (i) to characterize relevant lung cancer data repositories in Australia for the nature of data collected, patterns of data flow, linkage between repositories and barriers to access; (ii) to identify particular gaps and inconsistencies including range of data collected, missing crucial data items such as TNM staging and co-morbidities in population-based datasets, the age of the information collected, time delays for access and failure to link data on individual cases between separate datasets (iii) to identify potential innovative data strategies for clinicians including the routine collection of a small prospective, real-time dataset that is highly relevant and readily available for feedback in the clinical practice setting. Methods: Existing databases and registries in Australia will be canvassed from publicly available sources including database websites, registry websites, publications, research output and position papers. Relevant data custodians will be contacted and questioned on the content, remit and linkage of databases. A test data question will be developed for application in the current setting to identify key data gaps on clinical practice, for example, "What proportion of stage IIIA lung cancer patients in Australia have treatment that includes curative-intent surgery?". Results and Conclusions: The results of this study will help clinicians understand the strengths and limitations of currently available datasets relevant to lung cancer. This will help build strategies to improve access to and relevance of data for lung cancer clinical care in Australia. Background and Aims: The efficacy of F-18 FDG PET/CT is controversial in regions endemic for granulomatous disease. The accuracy and specificity of F-18 FDG PET are substantially reduced because of falsely increased F-18 FDG uptake in inflammatory nodes. The aim of this study was to evaluate qualitative interpretation of F-18 FDG-PET/CT for evaluation of mediastinal nodes to distinguish between malignant and benign lesions compared with qualitative F-18 FDG-PET/CT parameters. Methods: Sixty-five patients with pathologically documented non-small cell lung carcinoma who showed bilateral F-18 FDG avid mediastinal lymph nodes on pre-treatment staging F-18 FDG PET/CT image were included in a prospective cohort study. Seventy-nine mediastinal nodes were pathologically analyzed through endobronchial ultrasound transbronchial needle aspiration or lymph node dissection. SUVmax, SUVmax/liver, SUVmax/ blood pool and SUVmax/contra (SUVmax of significantly hypermetabolic lymph node adjusted to SUVmax of contralateral interlobar or hilar lymph node with increased glucose metabolism) were obtained as quantitative parameters to identify metastatic mediastinal nodes. Results: Qualitative evaluation showed sensitivity, specificity, positive predictive value and negative predictive value for separating metastatic lymph node from benign reactive hyperplasia of 97%, 97%, 96%, 85%. SUVmax and normalized SUVmax to liver and blood pool did not significantly differentiate between benign and metastatic lesions. However, SUVmax/contra was significantly higher for metastatic lesion than benign lesions. (p < 0.05) Reciever-operating-characteristic derived SUVmax/ contra cutoff was 1.43 (Area under the curve, 0.852) and sensitivity and specificity was 80% and 96%. Conclusions: Qualitative interpretation of F-18 FDG PET/CT was superior to quantitative parameters in discriminating metastatic lymph nodes from benign reactive hyperplasia in patients with bilateral F-18 FDG avid mediastinal lymph nodes. SUVmax/contra has better sensitivity and specificity than SUVmax, SUVmax/liver and SUVmax/blood pool. Background and Aims: Lung cancer are the second highest cases after TB in their incidence and prevalence at Pulmonology Department of Dr. Soetomo General Hospital since 2000 until 2016. Lung cancer itself has it unique dynamic and changings in it type cells, sex and age. Objective: Understanding lung cancer distribution pattern based on gender and ages of the patients and histopathology type of lung cancer. Methods: Descriptive analytic study using cross-sectional design. Data were retrieved from medical record among all patients who were admitted in Lung Ward at Dr. Soetomo General Hospital, during 1 January until 30 May 2016. Results: Our research revealed that the prevalence of lung cancer in Januari-May 2016 period are 300 patients. Lung cancer is more frequent in male than female (219 males vs 81 females). Based on ages span, most of lung cancer patients who were admitted in Lung Ward are in the group of 45-64 years old (176 patients). Based on cell types, the most common cellfinding in histopathology diagnostic are Adenocarcinoma (150 patients), followed by Squamous Cell Carcinoma (110 patients), Large Cell Lung Carcinoma (25 patients), and the least Small Cell Lung Carcinoma (15 patients). Conclusions: Lung cancer was three times more frequent in men than in women. Women with lung cancer were younger than men and smoked less intensively. Over-representation of adenocarcinoma was observed in the women, while squamous cell carcinoma often found in men. Women with lung cancer had a better prognosis than men. Background and Aims: Ectopic thymomas account for less than %5 of all thymomas and occur in the neck, posterior and middle mediastinum, lung, and pleura. They rarely present as huge pulmonary masses. Methods: A rare case of a giant intrathoracic ectopic thymoma with a significant response to chemoradiotherapy is described. A 44 year-old male consulted our hospital because of two giant lesions in the left hemi thorax detected by Chest computed tomography (CT). He had a 3-month history of a history of cough, dyspnea, chest pain, and fatigue. Chest CT showed a paramediastinal well-defined soft tissue mass (9.9x11.7x19.5 cm) on the anterior of the left upper lobe, an another mass (8.3x9.5 cm x17.3 cm) on the superior segment of the left lower lobe extending from hilum to the level of hemi diaphragm, and a 1.3 cm sub pleural nodule on the posterior segment of the left upper lobe. Because no definitive diagnosis could be made by two transthoracic needle biopsies at the local hospital and the progression of the lesions, thoracotomy was performed with multiple biopsies in our center. On the thoracotomy, lesions were found to be unresectable due to the invasion of the chest wall, mediastinum, and major vascular structures. Histology of the mass was consistent with type B1 and type B2 thymoma. Because of the large volume of the lesions, he was first treated with chemotherapy with 6 courses (Etoposide and cisplatin) and the response to the chemotherapy was partial. Then, he received an external radiotherapy with a dose of 55.8 Gy/31 fractions and a good partial response was obtained on CT scan of the thorax four months after the radiotherapy. Conclusions: When a patient presents with intrathoracic giant masses, ectopic thymoma should be considered in the differential diagnosis. Akita University Graduate School of Medicine, Cardiovascular and Respiratory Medicine, Akita, Japan, and 2 Akita University Graduate School of Health Sciences, Physical Therapy, Akita, Japan Background and Aims: Tumor angiogenesis is important in relation to growth or metastasis in lung cancer. The number of endothelial progenitor cells (EPCs) is angiogenesis marker that differentiates into tumor vessels. High concentrations of EPCs are associated with an acceleration of angiogenesis. We have evaluated the relationship between the number of EPCs when treated with chemotherapy in combination with Bevacizumab and the curative effects in non-small non-squamous lung cancer patients. Methods: Untreated 25 patients diagnosed with non-small non-squamous lung cancer were enrolled. EPCs were defined as CD34 antibody positive and vascular endothelial growth factor receptor-2 (VEGFR2) antibody positive. Flow cytometry was used to measure the number of circulating EPCs in the peripheral blood before chemotherapy. Patients were divided into two groups relative to the level of EPCs: high EPCs group and low EPCs group. In each group we compared the tumor reduction ratio, progression-free survival, the objective response ratio, and the disease control ratio with or without administering Bevacizumab in combination. Results: In the low EPCs group, there were no significant differences in the tumor reduction ratio, progression-free survival, the objective response ratio and the disease control ratio in the presence or absence of Bevacizumab. However, in high EPCs group, chemotherapy in combination with Bevacizumab produced a higher tumor reduction ratio and longer progression-free survival compared to the absence of Bevacizumab. Conclusions: In non-small non-squamous lung cancer, the effect of the chemotherapy may be improved in patients with high EPCs by a combination with Bevacizumab. Showa University, Division of Respiratory Medicine and Allergology-Department of Internal Medicine, Tokyo, Japan, 2 Showa University, Department of Medicine-Division of Medical Oncology, Tokyo, Japan, and 3 Showa University, Institute of Molecular Oncology, Tokyo, Japan Background and Aims: More than 50% of lung cancer patients are diagnosed when they are over the age of 65, and about 30% are over 70. Elderly patients are at higher risk of treatment-related death and toxicity.The aim of the present study was to assess the antitumor activity and toxicity of chemotherapy in elderly patients with previously untreated SCLC retrospectively. Methods: From Jarnuray 2002 through December 2011, 96 patients with SCLC were 70 years or older treated with chemotherapy in showa university. Results: The median age of the patients was 76 years (range, 70-91 years). 33 patients had limited disease and 63 patients had extensive disease. Chemotherapy regimens were carboplatin + etoposide + concur-rentTRT(n = 5),cisplatin + etoposide + concurrentTRT(n = 1),carboplatin + etoposide(n = 15),cisplatin + etoposide(n = 5) carboplatin + irinoteecan (n = 50),etoposide alone(n = 3),irinotecan alone(n = 6). The overall response rate was 72%(95% CI: 65.3-94.4%). The median survival time was 13.4 months. The median progression free survival time was 9.5 months. Grade 3 to 4 hematologic toxicities included neutropenia in 80% of patients, thrombocytopenia in 46%, and anemia in 44%. Grade 3 to 4 nonhematologic toxicities included diarrhea in 9% of patients, infection in 7%, and appetite loss in 3%. The 3 treatment-related death were due to infection. But there were no drug induced pneumonitis. Conclusions: This combination chemotherapy is effective for SCLC and tolerable for elderly patients. Background and Aims: Thymic large cell neuroendocrine carcinoma belongs to the subgroup of thymic carcinoid, which is part of thymic carcinoma. According to WHO classification, it is under the poorly differentiated category. 1 Thus far, the reported incidence of thymic carcinoid was 0.02/100,000, 2 It has a male preponderance and is symptomatic in two third of cases. 2 Here, we describe the first local encounter of such rare tumour and to share our experience in clinching the diagnosis, and review of past literatures on this rare case. Results: A 69-year-old man came to our tertiary hospital with a 2-week history of hoarseness of voice associated with dry cough. He was first assessed by otorhinolaryngologist and laryngoscopy revealed paralysis of left vocal cord. Subsequent computer tomography (CT) imaging demonstrated the anterior mediastinal mass (8.0 x 8.0 x 9.3 cm) compressing the recurrent laryngeal nerve, with left pleural effusion. (Figure 1 + 2) Succeeding ultrasound guided biopsy of the mass confirmed the diagnosis of thymic large cell neuroendocrine tumour, with Ki67 index of more than 90%. Options of surgical resection followed by adjuvant chemoradiation were explored. Nonetheless, he opted for traditional treatment. Two months later, he presented again to us with acute dyspnoea complicated with cardiac tamponade. He succumbed to death due to severe respiratory distress. Conclusions: Large cell neuroendocrine thymic carcinoma is the subcategory that carries worst prognosis. In Italian case series, ten-year survival rate has been documented to be 0%. 4 It can be difficult to diagnose via standard needle biopsy due to the inhomogeneous nature of the thymic mass. 5 Although thymic carcinoid has been recognized nearly half a century ago, 6 till date there is no standardised treatment modalities. This case highlights the aggressive nature of the disease with its dismal outcome. We hope to stir up continuous search for optimal management strategy for this type of malignancy. However, the addition of celecoxib to chemotherapy in clinical trials failed to benefit the survival of NSCLC patients. In this study, to re-evaluate the therapeutic potentials of celecoxib for NSCLC, we herein attempted to examine the cellular impacts of celecoxib, on NSCLC cells, in particular on EMT process. Methods: We evaluated the efficacy of celecoxib depending on the amount of dose in TGF-β1-induced EMT. EMT-related molecular alterations were detected by western blotting and ECIS. In addition, STAT5b and AKT were knocked down or overexpressed to determine its role in preventing TGF-β1-induced EMT by celecoxib. Results: Celecoxib in high dose was effective in preventing TGF-β1induced EMT, as indicated by upregulation of E-cadherin, and downregulation of mesenchymal markers and transcription factors. On the other hand, celecoxib in low dose rather promoted TGF-β1-induced EMT. We found from phopho-kinase array kit that the different effects resulted from the two different doses of celecoxib, 2 μM and 20 μM, used were related to STAT 5b and AKT proteins. In addition STAT5b or AKT downregulation enhanced reverse of TGF-β1-induced EMT by high dose of celecoxib. In contrast, AKT upregulation had a relevant role in TGF-β1-induced EMT. Conclusions: Different doses of celecoxib used showed the opposite effects on TGF-β1-induced EMT through STAT5b and AKT pathway. We show for the first time the molecular mechanisms underlying the efficacy of celecoxib in NSCLC cells. Background and Aims: Randomised control trials demonstrate first-line pemetrexed combined with platinum is more effective than first-line gemcitabine combined with platinum in advanced lung adenocarcinoma. To date, there is no study in Malaysia that compares the efficacy of pemetrexed versus gemcitabine combined with platinum in the first-line treatment of advanced lung adenocarcinoma. This study aims to compare the progression-free survival (PFS), overall survival (OS), objective response rate (ORR) and disease control rate (DCR) of Malaysian patients with advanced lung adenocarcinoma receiving first-line chemotherapy with pemetrexed/carboplatin versus gemcitabine/carboplatin. Conclusions: Malaysian patients with advanced lung adenocarcinoma appeared to have similar PFS, OS, ORR and DCR irrespective of whether they received pemetrexed/carboplatin or gemcitabine/carboplatin as firstline treatment. However, the apparent lack of differences could have been due to the small sample size. Background and Aims: A family history can be a valuable tool in the era of big data and genomic medicine. A few studies have reported on an association of family history of lung cancer with EGFR activating mutation. However, their impact on survival of lung cancer patients remains to be investigated. Methods: A consecutive 829 patients who were histologically diagnosed with non-small-cell lung cancer from January 2006 through January 2014 and who had received an analysis of EGFR activating mutation in a prospective lung cancer cohort were included in this study. An association of the EGFR mutation with their family history of lung cancer in first-degree relatives was evaluated with multivariate logistic regression analysis. Its impact on survival of the patients by the family history was estimated with Cox proportional hazards model. Results: Seventy five (9.0%) patients had family history of lung cancer. The EGFR mutation was commonly observed in patients with the family history when compared to those without the family history (46.7% v 31.3%, χ 2 p = 0.007). The family history was shown to be significantly associated with the EGFR mutation (aOR and 95% CI: 2.01 and 1.18-3.60, p = 0.011). Patients with the family history had marginally longer survival when compared to those without the family history (MST, 26.4 v 15.8 months, log-rank p = 0.091). The presence of the EGFR mutation had a significant impact on the survival in patients without the family history (aHR and 95% CI: 0.72 and 0.57-0.90, p = 0.005) while this impact was not observed in patients with the family history (aHR and 95% CI: 1.01 and 0.50-2.36, p = 0.832). Conclusions: The family history of lung cancer was associated with the prevalence of EGFR mutations and may modify the impact of EGFR mutation on survival of lung cancer patients. Background and Aims: Epigenetics has been raised as a hallmark of cancers over the last decade. It plays a key role in the function and regulation of gene without the alteration of nucleotide sequence. The objective of this study is to develop the detection and quantification of the modification of DNA methylation for the early cancer diagnostic test. Methods: Oligonucleotide design Based on bisulfite modification methods, we used methylated probes that contain methylated cytosine (mC) and unmethylated probe that contain thymine (T) instead of uracil, based on a previous study (Ref. Shin et al.) . The methylate and unmethylated targets are the complementary sequences of methylated and unmethylated probes, respectively. For DNA target binding analysis, oligonucleotides were dissolved in DNase and RNase free water. Methylated or unmethylated target was added to methylated and unmethylated probes at 1:1 ratio, and then the mixtures were incubated for 5 min at room temperature for hybridization. Raman spectroscopy Raman spectra of bench top type were taken by using a spectroscopy (BRUKO, GERMAN) with a diode laser beam at an excitation wavelength of 785 nm. The bench top Raman scattered light signal was collected in x50 object lens. The laser source with a power of 25 mW was focused on a sample with a spot diameter of~2um. Results: We observed that Raman spectra of CDH1 Met (methyl) Probe are similar to those of CDH1 UnMet (unmethyl) Probe like Raman spectra of CDH1 Met Target are similar to those of CDH1 UnMet Target. Considering the mixtures shown in figure 1 , they can also be differentiated from the others. Conclusions: Raman detection system will be helpful to develop a pointof-care-test diagnostic chip for DNA methylation detection in clinical cancer researches. Background and Aims: Atrial fibrillation is common arrhytmia and its prevalence increases with age. Cardiac rhythm disturbances are common concern among patients with neoplastic diseases. Arrhytmias may be due to the effects of the tumor itself (extrinsic compression of the heart), involvement of the coronary vasculature, treatment of the neoplastic process, or metabolic and autonomic instability. The relationship between chemotherapy and arrhytmias has not been well established. Monitoring would be prudent in lung cancer patient with atrial fibrillation receiving chemotherapy. A 62-years-old Balinese male presented with dyspnea, dizziness, palpitation and cough. An examination revealed a mass right upper chest, atrial fibrillation, and postural drop in blood pressure. CT scan thorax showed hyperdense mass with high contrast enhancement, right pleural effusion, metastatic process in sternum, corpus vertebrae thoracal 10. Biopsy from mass in the chest revealed squamous cell carcinoma. He was treated with systemic chemotherapy using carboplatin and vinorelbine. Following this treatment this patient has not experienced progression of atrial fibrillation. Discussion: Treatment of lung cancer with chemotherapy in patient with atrial fibrillation should be done with close monitoring. Chemotherapy agent was chosen based on report regarding atrial fibrillation induced by cancer chemotherapy. The incidence and severity of drug induced atrial fibrillation depend on the drugs used, dose and schedule employed (particularly with combination therapy), age of patients, and presence of an arrhythmogenic substrate created by cancer and/or chemotherapy. The regimen chosen were combination carboplatin and vinorelbine which has less atrial fibrillation side effects. Background and Aims: Pulmonary embolism is a potentially lifethreatening complication of lung cancer surgery, and remains a difficult challenge for thoracic surgeons. The purpose of this study was to assess the measurement of D-dimer concentration as a preoperative screening test for venous thromboembolism in patients with non-small cell lung cancer. Methods: From August 2008 to December 2014, the preoperative Ddimer plasma concentration was determined for 382 patients with nonsmall cell lung cancer, who underwent surgery. There were 222 male and 160 female patients, with a median age of 65 years. The pathologic diagnosis was adenocarcinoma in 280 patients, squamous cell carcinoma in 67, and other in 35. On pathological staging, 278 patients had stage I, 55 had stage II, and 49 had stage III disease. The D-dimer concentration was determined using a latex agglutination assay. Lower limb venous ultrasonography was performed for patients with a D-dimer plasma concentration higher than the cut-off value (1.0 μg/mL). Results: The median preoperative D-dimer concentration was 0.7 μg/mL, range 0.24-12.62 μg/mL. Of 382 patients, 105 (27%) had a D-dimer concentration higher than the cut-off value, and 18 (5%) were positive for deep vein thrombosis on venous ultrasonography. Anticoagulant therapy was administered to these 18 patients during the postoperative period, because they were at very high risk for pulmonary embolism. None of the study patients developed postoperative pulmonary embolism. Conclusions: Preoperative measurement of the D-dimer concentration of lung cancer patients may be a useful screening method for identifying patients at high risk for pulmonary embolism. Background and Aims: The risk for malignancy increases in persons living with HIV (PLHIV). Lung cancer incidence is increased two-folds in PLHIV, with pulmonary adenocarcinoma representing the majority of non-AIDS defining lesions. Concurrent use of cytotoxic chemotherapy with anti-retroviral therapy (ART) may result in additive cytotoxicity or other drug-drug interactions and may further enhance immunosuppression. To date, few data exist on the efficacy and toxicity for chemotherapy. Methods: We report a case of lung adenocarcinoma with PLHIV. A 43year-old Filipino male who presented with 4-month history of productive cough initially treated as clinically-diagnosed pulmonary tuberculosis. With progression of signs and symptoms, diagnostic work-ups revealed an HIV-positive result with a 25 cell/uL CD4 Cell count. He also presented with right-sided pleural effusion, cell block cytology revealed adenocarcinoma, EGFR-positive. As a patient presenting with two major problems that needed prompt treatment, he was started on oral chemotherapeutic agent Erlotinib and anti-retroviral therapy regimen with Zidovudine-Lamivudine-Efeverenz. Results: The presence of activating mutations within the epidermal growth factor receptor (EGFR) gene of lung cancer cells makes these tumors highly sensitive to EGFR-targeting tyrosine kinase inhibitors (TKIs) such as erlotinib and gefitinib. Mutation incidence in HIVassociated lung cancer is not known. Few data exist on chemotherapy with ongoing antiretroviral therapy. Reversal of immunosuppression in PLHIV is important because median survival improves with CD4 cell count more than 200 cells/μL. The simultaneous use of ARVs and chemotherapeutic agents is a challenge due to significant increase in myelosuppression. Efavirenz could potentially decrease erlotinib concentrations. Concurrent ARVs are expected to exacerbate side effects of chemotherapy and perhaps make cancer therapy intolerable. Conclusions: It is important to consider the choice of chemotherapy and antiretroviral treatment in the management of lung adenocarcinoma in PLHIV. Strict monitoring should be done to note drug interactions to minimize and prevent adverse interactions thereby providing optimal treatment of both diseases. Background and Aims: The imbalance between endogenous proteases and inhibitor of proteases is one of the critical mechanisms of chronic obstructive pulmonary disease (COPD). Cystatin C is a classical inhibitor of endogenous cysteine proteases, and its association with COPD is limited. Our study aimed to investigate the serum levels of Cystatin C in COPD patients and discuss its potential clinical significance. Methods: Serum samples were collected from both 140 COPD and 140 health controls. All the subjects finished standard lung function test. Serum levels of Cystatin C and C-reactive protein were determined. Relationships between Cystatin C concentration and lung function, CRP and other indices were assessed by Pearson's correlation test. Results: Mean serum levels of Cystatin C were significantly higher in COPD patients than in controls (1.08 AE 0.24 versus 0.99 AE 0.34 mg/L, p = 0.025). Serum levels of CRP were also significantly higher in COPD patients (8.80 AE 6.94 versus 3.99 AE 3.10 mg/L, p < 0.05). Serum levels of Cystatin C in COPD patients correlated inversely with FEV1% predicted, an index of lung function (r = −0.237, p = 0.005), while they correlated positively with C-reactive protein levels, an indicator of systemic inflammation (r = 0.277, p = 0.001), and COPD assessment test scores (r = 0.200, p = 0.018). Conclusions: Our results suggest that serum levels of Cystatin C are increased in COPD patients and that they are associated with lung function, COPD assessment test score and systemic inflammation in COPD patients. Future studies should be performed to determine how Cystatin C plays a role in COPD. A. EBIHARA Tokai University tokyo hospital, Pulmonology, Tokyo, Japan Background and Aims: Bronchial asthma patients with smoking history, that the number of patients including the ratio of COPD. There is a new phenotype called asthma COPD overlap syndrome (ACOS). In elder patients (over 65 years) it seems more difficult to differentiate between asthma and COPD. In this study, in asthma patients with smoking history, we went whether retrospective analysis how much ACOS is included. Methods: A total of 78 subjects (male 37, female 41, age 68 years old AE17 years old AE SD), were enrolled into the study after informed consents were obtained until July 2010 from August 2007 in Erimo town clinic in Hokkaido.It was that retrospective study analysis was performed asthma control status and medication history, smoking history. Results: Control state, mild intermittent type 29/78, mild persistent type 23/78, moderate persistent 18/78, severe persistent 8/78. Medication history, ICS single agent 12 people, ICS / SABA 4, ICS / LABA 28, ICS / leukotriene antagonist 9, ICS / SABA / leukotriene 4, ICS / LABA / leukotriene 18, theophylline 48/78 (62%). In addition, LAMA was five (6%). Conclusions: Because we had no concept of ACOS at 2007, in many cases had been treated separately with asthma and COPD. Among them, ACOS were expected to be more than 50% in uncontrolled asthma patients.In the treatment of elderly patients with asthma, it was suggested that there is a need for aggressive use of LAMA in consideration of the ACOS. Background and Aims: Cigarette smoke (CS)exposure is associated with an increased risk of COPD. The levels of inflammation are very high in the lung tissue of the COPD patients. The receptor for advanced glycation end products (RAGE) is a multiligand receptor that can amplify inflammatory responses. In this study, we investigated the role of RAGE signaling in the pro-inflammatory responses induced by CS. Methods: Wide-type BALB/c (WT) mice and RAGE knockout (KO) mice were exposed to mainstream CS or room air for 2 hours twice daily, 6 days per week for 4 weeks. Bronchoalveolar lavage fluid (BALF) were acquired for cell counting and measurement of pro-inflammatory cytokines levels. Lung tissues were collected for histological examination and gene expression profiling with Affymetrix mouse genome 430-2.0 GeneChip. Results: Compared with the sham-exposed controls, neutrophil counts and pro-inflammatory cytokines ( IL-1β, IL-6 and TNF-α )levels in the BALF were significantly increased after CS exposure in wild-type mices, as well as CS-induced thickening of the airway epithelium, peribronchial inflammatory cell infiltration and airway obstruction. However, knockout of RAGE significantly attenuated the CS-induced inflammatory responses and histological alterations in mouse airways. Furthermore, compared to the CS + WT mice, a total of 179 upregulated genes and 351 downregulated genes after CS + KO, as well as 2-4 times of RAGE common ligands (S100A8,S100A9,S100A14) decreased. Conclusions: These results suggest that RAGE signaling as a potential important therapeutic target contributes significantly to cigarette smokeinduced lung and systemic inflammation. Acknowledgement: This study was supported in part by grants 81200031 and 81230001 from the National Natural Science Foundation of China and grant 2014SCU04A11 from the Science Foundation for Outstanding Young Scholars of Sichuan University. Background and Aims: Irisin, one of the myokine, is a newly identified hormone secreted by skeletal muscle. Irisin has been proposed to mediate various beneficial effects on metabolic disorders such as diabetes mellitus, osteoporosis or cachexia. Sarcopenia, loss of skeletal muscle mass and strength, is a one of the comorbidity of chronic obstructive pulmonary disease (COPD) subjects, which might lead to poor QOL and prognosis. This study was designed to evaluate irisin levels of COPD subjects with sarcopenia and to examine relationships between irisin levels and pulmonary function measurements in COPD subjects. Methods: Twenty-six stable male COPD subjects were enrolled. Pulmonary function testing was performed and body composition was evaluated by the bio-impedance method (BIA). Sarcopenia was defined with Skeletal Muscle Index (SMI). Peripheral blood irisin levels were measure by ELISA. Results: Irisin levels were significantly correlated with muscle mass, Fat Free Mass (FFM), Fat Free Mass Index (FFMI), and body mass index (BMI). However, the difference in irisin levels between COPD subjects with and without sarcopenia did not reach statistical significance when subjects were stratified by algorithms including SMI and grip strength. Irisin levels were significantly correlated with V50/V25 and DL/VA, while they were not correlated with %FVC and %FEV1. Conclusions: Irisin levels were related with loss of muscle mass in COPD subjects. Furthermore, irisin levels were related with impaired pulmonary function in COPD subjects. Irisin might be a biomarker for muscle-pulmonary or vice versa interaction in COPD subjects. Further investigations were desirable. Background and Aims: The St George's Respiratory Questionnaire scores(SGRQ) was developed as an instrument to assess health status in patients with COPD. The longitudinal changes in health status are well described, but less is known about baseline characteristics of the patients who deteriorated in health status with mild to moderate COPD. This study aimed to investigate the baseline characteristics of aggravating SGRQ group and to identify the factors associated with aggravating change in SGRQ score Methods: The St George's Respiratory Questionnaire scores(SGRQ) was developed as an instrument to assess health status in patients with COPD. The longitudinal changes in health status are well described, but less is known about baseline characteristics of the patients who deteriorated in health status with mild to moderate COPD. This study aimed to investigate the baseline characteristics of aggravating SGRQ group and to identify the factors associated with aggravating change in SGRQ score Results: 52 of a total 126 patients (41.3%) were belonged to the improving group, 40 (31.7%) patients were in stable group and 34 (27.0%) were in the aggravation group. Comparing baseline characteristics at each group, the FEV1 of deteriorating group was lower than the other groups (p = 0.007) and modified Medical Research Council (mMRC) score was higher significantly (p < 0.001) in using ANOVA t -test. In addition, the risk factors of deteriorating SGRQ group were mMRC(p = 0.031) and acute exacerbation(p = 0.021) by logistic regression analysis. When we analyzed 3 year changes of each parameter in each group, FEV1, FEV1/FVC and BMI decreased and mMRC increased significantly in deteriorating group. In deteriorating group, acute exacerbation was frequent (58%, odd ratio 2.43 95% confidence interval 1.09 to5.44; P = 0.042). Conclusions: The predictors of SGRQ aggravation were lower FEV1 (p = 0.007), higher mMRC(p < 0.001) at baseline and acute exacerbation during follow up periods. Background and Aims: The exacerbation was the most common cause of hospital admission in COPD, it varied in severity, increased health care cost, lead to decrease quality of life, diminished lung function, weakness, reexacerbation or rehospitalization, even death. The accurate prognostic tool for acute exacerbation help assessment, appropriate management and improved outcome. However, the prognostic tools in exacerbations was limited. Bourke et.al and Nafae et.al studies showed the DECAF score was a promising tool for AECOPD, it was simple and effective predictor of mortality. The aim of this study was to validate the DECAF score as a promising prognostic tool for AECOPD and to compare the accuracy of DECAF score versus CURB-65 in predicting mortality risk among AECOPD. Methods: All AECOPD patients who admitted from August 2014 until August 2015 invited to participate in this study voluntarily. All informations would be keep confidential. All participants assessed, stratified using DECAF and CURB-65 score to predict the mortality risk in 28 th days, length of hospital stayed and time to next exacerbation. Statistical analysis was done using Epi info7, SPSS, Pearson's Chi-Square and Anova analysis. Results: The picture of COPD patients in CSMC were similar with the world. Most of them were eldery (X 76.70 AE 10.20), majority were men ( 82.61%), mostly had history of heavy smoker (91.3%) : 30 -80 packs year (X 55.91 AE 31.86). However our study was fail to affirm previous studies that the DECAF score is a promising prognostic tool for AECOPD assessment. Conclusions: The DECAF score was probably not superior than CURB-65 as a prognostic tool for AECOPD. The limitation of our study was we did not have enough sample size to get a valid results. Our suggestion to improve this study was to prolong the study and or to do multicenter studies. Background and Aims: Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease which differs in clinical manifestation, structural change, and response to treatment. We aim to identify subgroups of COPD in a cohort study using cluster analysis at baseline and to assess clinical outcomes of each subgroup during one year of follow-up. Methods: We analyzed 203 patients from COPD in dusty area cohort. Main factors were selected with the highest loading in 15 variables using the principal component analysis (PCA) at baseline. COPD patients were classified using hierarchical cluster analysis with clinical, physiological and imaging data based on PCA-transformed data. The clinical parameters were evaluated among subgroups. Subgroups were also evaluated for their clinical outcomes during one year of follow-up. Results: PCA showed that six independent components accounted for 77.3% of variance. Three distinct subgroups were identified by the cluster analysis. Subgroup 1 included younger patients with mild stage in GOLD and had fewer exacerbations and hospitalizations during one year of follow-up. Subgroup 2 included more female patients with milder severity and had more severe respiratory symptoms and showed more progress of symptoms. Subgroup 3 included more severe subjects and had the largest decline of FEV1 and the most exacerbations during one year. Conclusions: Cluster analysis using baseline data in a COPD cohort identified three distinct subgroups that differ in clinical parameters, and clinical outcomes. These findings suggest that the identified subgroups may represent clinically meaningful subtypes of COPD. Background and Aims: It is believed that lung function tests are indispensable for the diagnosis of chronic obstructive pulmonary disease (COPD); however, these tests depend on the inspection procedure and patient efforts, which cannot be enforced by many facilities. Herein, we confirmed that the %FEV1 and FEV1% correlated with lateral-view inspiratory-expiratory chest radiography findings. Moreover, it has also been reported that the RV/TLC and IC/TLC ratios are associated with acute exacerbation and prognosis in COPD patients. Here, we aimed to determine if lateral-view chest radiography is useful for predicting the precise respiratory function in COPD patients. Methods: Fourteen patients diagnosed with COPD based on the Japanese Respiratory Society COPD guidelines, who underwent lateral-view inspiratory-expiratory chest radiography in our hospital, were analyzed. By using the clinical image viewer ShadeQuest/ViewC v.2.00, we measured the vertical directions between the apex and the diaphragm and the anteroposterior diameters of the thoracic cavities, and calculated the cavity areas. The associations between these measurements and the precise breathing function test values were investigated. Results: Significant correlations of the diameter from the apex to the diaphragm and anteroposterior diameters of the thoracic cavities with the % RV and RV/TLC ratio were noted. In particular, the RV/TLC ratio showed a strong correlation with the difference in the vertical size between inspiratory and expiratory chest radiography (R = -0.76, p < 0.01). When the cutoff value was set as 12 mm, RV/TLC ≥40 could be detected with a sensitivity of 83%, specificity of 87%, and area under the curve of 0.88. However, no significant relationships among these diameters and the % FRC, %TLC, IC/TLC, and %DLco/VA were observed. Conclusions: Inspiratory-expiratory lateral-view chest radiographs were considered useful in predicting the precise respiratory function in COPD patients. Background and Aims: COPD exacerbation is associated with decrease in lung function and quality of life. The identification of specific factors may affect the prognosis, management and outcome of each exacerbation. Though several scoring systems have been proposed, some remain subjective and difficult to evaluate. Furthermore, some clinical and laboratory markers, deemed important in certain studies, were not included. Based on previous studies, the aim of the study is to determine the factors affecting the outcome of acute exacerbation of COPD. Methods: Subjects admitted due to an acute exacerbation of COPD aged 40 years old and above from 2012-2015 were included. Patients' charts were retrieved and specific factors were recorded and outcomes such as in-hospital mortality, need for mechanical ventilation and ICU admission were recorded. Logistic regression analysis was then done to determine statistical significance. .001] were associated with increased in-hospital mortality during an acute exacerbation of COPD. These were also observed as to the need for invasive mechanical ventilation and ICU admission. In addition, MRC dyspnea score of 4 was found to be significant for the need for invasive mechanical ventilation [OR = 23.91,p = <0.001] and need for ICU admission [OR = 26.84,p = <0.001]. However, the presence of diabetes mellitus [OR = 0.37,p = <0.001] was found to be a protective factor for in-hospital mortality. Conclusions: Prognostic factors such as older age, malnutrition, severe MRC dyspnea score, hypoalbuminemia, elevated urea, anemia and severe acidosis significantly increases in-hospital mortality, need for invasive mechanical ventilation and ICU admission during an acute exacerbation of COPD. On the other hand, a controlled diabetes mellitus has shown to lower risk for in-hospital mortality. Batangas, Philippines, and 2 Quezon City, Philippines Background and Aims: Chronic obstructive pulmonary disease (COPD) is etimated to affect 10% of the population worldwide and is an important cause of mortality and morbidity. Traditional spirometric measurements such as FEV 1 correlate poorly with exercise tolerance and exertional dyspnea that is associated with lung hyperinflation which can be measured by lung volume study. This research identified the presence of hyperinflation and their association even with mild stage and among those with increasing levels of COPD severity. Methods: Prospective cohort analytic study among COPD patients diagnosed by pulmonary function test, consistent with airflow obstruction. Lung volume study was done among those who do not have lung volume study. An analysis of variance were used for the association of TLC, RV and RV/TLC ratio on the different levels of COPD severity based on GOLD citeria. A p-value of ≤ 0.05 was considered significant. Results: 74 patients were included in the study. 59 patients (80 %) were male and 15 (20 %) were female. The mean age of the study population was 62 years old. Majority of the patients (93 %) were smoker. The mean FEV 1 was 52 % predicted in the post-bronchodilator study. Most of the patients were at GOLD 2 with 33 patients (45%). What was observed was as COPD severity increases, there was also an increasing RV/TLC ratio. However, looking at the changes between one category to the next, the change in RV/TLC was significantly increased between GOLD 1 and 3 (pvalue of 0.043) and GOLD 1 and 4 only (p-value of 0.008). Conclusions: RV/TLC ratio can serve as a good objective parameter for hyperinflation where the ratio increases in direct association with increasing COPD severity. This association is more significantly noted when COPD patients are in GOLD 3 and 4 cataegory. Background and Aims: Chronic obstructive pulmonary disease (COPD) is an important disease worldwide in both high-income and low-income countries. By the year 2020, it has been estimated that COPD will rank fifth among the conditions with a high burden to society and third among the most important causes of death for both genders worldwide. Sweeping as a work job and employment, is specially thought and considered to be a menial one. During sweeping activity sweepers are exposed to the dust and it cause various ill effects in the body. Street dust is a complex mixture of soil dust, plant fragments, dust from motor vehicles and other biological materials. The street sweepers are exposed to dust particles, bioaerosols and various harmful gases. The street sweepers usually would not use protective devices and exposure to the air pollution during sweeping may have contributed to increase in the prevalence of COPD. This is a preliminary (cross sectional) study of prevalence COPD among street sweepers in Jakarta, Indonesia and have been approved by ethical committee faculty of medicine Universitas Indonesia. Methods: This research design is cross-sectional with the subjects are street sweepers in Jakarta. Sample collection using a cluster random sampling through questionnaires of COPD Assessment Test (CAT) and The Modified British Medical Research Council (mMRC), spirometry examination based on Pneumobile Project Indonesia, bronchodilator test. The inclusion criteria are male and female, able to perform spirometry, signed an informed consent, over 40 years old, work period >2 years. Results: Thirty subjects participated in the study, most aged 41 to 50 years that is 21 male (70%) and 9 female (30%). Prevalence of COPD among street sweepers in the same area is 6,6%. Conclusions: Prevalence of COPD among street sweepers in Jakarta is 6,6%. National Heart and Lung Institute-Imperial College London, Airways Disease Section, London, United Kingdom, 2 Asthma and Airway Centre-University Health Network-University of Toronto, Department of Medicine, Toronto-ON, Canada, 3 Novartis Pharma AG, Respiratory, Basel, Switzerland, and 4 Novartis Pharmaceuticals Corporation, Respiratory, East Hanover-, NJ, USA Background and Aims: The GOLD guidelines recommend long-acting β 2 -agonist/inhaled corticosteroid combination and/or a long-acting muscarinic antagonist as the first-line therapy in COPD patients at a high risk of exacerbations [GOLD 2016 ]. The FLAME study evaluated the effects of IND/GLY versus SFC on reducing exacerbations in COPD patients at a high risk of exacerbations 1 . Methods: In this 52-week, multicenter, randomized, double-blind, parallel-group study, patients aged ≥40 years with moderate-to-very severe COPD (post-bronchodilator FEV 1 ≥ 25%-< 60%) and a history of ≥1 exacerbation in the previous year were randomized (1:1) to IND/GLY 110/50 μg once daily or SFC 50/500 μg twice daily. The primary endpoint was non-inferiority of IND/GLY to SFC in terms of rate of all exacerbations, with testing for superiority pre-specified if non-inferiority was established. Background and Aims: Long-acting β 2 -agonists/inhaled corticosteroids combination (LABA/ICS) and/or long-acting muscarinic antagonist (LAMA) are the recommended treatments for moderate-to very severe chronic obstructive pulmonary disease (COPD) patients at high risk of exacerbations (GOLD 2016). In the FLAME 1 study, indacaterol/glycopyrronium (IND/GLY, a LABA/LAMA) showed superiority in reducing exacerbations over salmeterol/fluticasone (SFC, a LABA/ICS) in COPD patients with a history of exacerbations. Here, we report the effects of IND/GLY on lung function and health-related quality of life (HRQoL) versus SFC from this study. Methods: In the 52-week, double-blind FLAME study, COPD patients with a history of ≥1 exacerbation in the past year, and a post-bronchodilator forced expiratory volume in one second (FEV 1 ) predicted ≥25% to <60%, were randomized (1:1) to receive once-daily IND/GLY 110/50 μg or twice-daily SFC 50/500 μg. Lung function was assessed using spirometry (pre-dose trough FEV 1 and forced vital capacity [FVC] , and standardized area under the curve for FEV 1 from 0 to 12 hours [FEV 1 AUC 0-12h ] in a subset of patients using serial spirometry), and HRQoL was evaluated in terms of St. George's Respiratory Questionnaire for COPD (SGRQ-C) total score at Day 1 (FEV 1 AUC 0-12h ), and after 4, 12, 26, 38, and 52 weeks of treatment (pre-dose trough FEV 1 , FVC, FEV 1 AUC 0-12h and SGRQ-C). Results: Of the 3362 randomized patients (IND/GLY, n = 1680; SFC, n = 1682), 82.2% completed the 52-week treatment period. IND/GLY showed significant improvements in pre-dose trough FEV 1 , pre-dose trough FVC, FEV 1 AUC 0-12h , and SGRQ-C score (except at Week 4) versus SFC over the 52-week treatment period (Table) . Conclusions: IND/GLY showed significant improvements in lung function, and health-related quality of life versus SFC, which was consistent over the 52-week treatment period. These results support the role of IND/GLY as a preferred treatment in COPD patients at high risk of exacerbations. Study funded by Novartis AG National Heart and Lung Institute-Imperial College London, Airways Disease Section, London, United Kingdom, 2 University of Marburg, Respiratory Diseases, Marburg, Germany, 3 Novartis Pharma AG, Respiratory, Basel, Switzerland, and 4 Novartis Pharmaceuticals Corporation, Respiratory, East Hanover-, NJ, USA Background and Aims: Baseline eosinophil levels may predict the efficacy of inhaled corticosteroids for prevention of COPD exacerbations. In this analysis from the FLAME study, we present the post-hoc evaluation of the time to first moderate or severe exacerbation with indacaterol/glycopyrronium (IND/GLY) compared with salmeterol/fluticasone (SFC) in moderate-to-very severe COPD patients stratified by baseline blood eosinophil levels. Methods: FLAME, a 52-week, multicenter, double-blind, double-dummy, parallel-group study randomized (1:1) patients with post-bronchodilator FEV 1 ≥ 25 -<60% predicted and a history of ≥1 exacerbation in the previous year, to receive either once-daily IND/GLY 110/50 μg or twice-daily SFC 50/500 μg. Data were analyzed by subgroups defined by percentage blood eosinophils (<2% and ≥2%) and absolute blood eosinophils levels (<150, 150-< 300 and ≥300 cells/μL). Results: Of the 3362 patients randomized (IND/GLY, n = 1680; SFC, n = 1682), 3345 patients were included in this analysis. The time to first moderate or severe exacerbation was significantly delayed with IND/GLY compared with SFC in subgroup of patients stratified by percentage blood eosinophils (<2% and ≥2%) and absolute blood eosinophils (<150 and 150-< 300 cells/μL). Furthermore, numerical improvement in the exacerbation risk in terms of time to first moderate or severe exacerbation was observed in the subgroup of patients with eosinophil count of ≥300 cells/ μL (Table) . Conclusions: In this study in patients with high risk of exacerbations, indacaterol/glycopyrronium was significantly better in delaying the time to first moderate or severe exacerbation than salmeterol/fluticasone at eosinophils cutoffs (<2% and ≥2%, and <150 and 150-< 300 cells/μL). At no given eosinophil cutoffs was salmeterol/fluticasone found to be better than indacaterol/glycopyrronium in delaying the time to first moderate or severe exacerbation. Study funded by Novartis Pharma AG Background and Aims: Background: WHO estimates, 65 million people have moderate to severe chronic obstructive pulmonary disease (COPD). More than 3 million people died of COPD in 2005, which corresponds to 5% of all deaths globally. It is known that almost 90% of COPD deaths occur in low-and middle-income countries. Across national and regional levels, limitations in policies need to be challenged and obstacles to effective care need to be removed. What we need is a robust policy framework to allow healthcare professionals to identify patients earlier and make the necessary interventions to tackle this disease effectively. Methods: By implementing effective treatment management protocols such as smoking cessation and a step wise approach to treatment, as recommended by the Global Initiative for Chronic Obstructive Lung Disease guidelines, disease progression may be delayed. Results: Expected outcomes: -Increase in the number of stakeholders trained in COPD advocacy. -Provide COPD advocacy training and technical assistance to patients and partners for regional and/or local advocacy. -Increase in the number of legislators who better understand COPD and related policies and programs -Increased public funding for COPD activities in the region More and better tobacco control and clean air policies at local and regional levels Conclusions: To address the escalating socio-economic burden of COPD, we need a clear and implementable strategy across Asia. The APSR and the local societies are working in partnership to improve diagnosis, management and also education about COPD. Background and Aims: Chronic obstructive pulmonary disease (COPD) is a frequent cause of morbidity and mortality in developing countries, which might be attributable to lack of knowledge of COPD patients. The main objective of this study was to evaluate the knowledge of COPD among Malaysian patients living with COPD. Methods: Post ethics approval and written consents, 110 COPD patients (≥40 years old; not diagnosed with or other respiratory disease; nil cognitive disability) attending follow-up appointment at Chest Clinic in Hospital Melaka were recruited. The patients' socio-demographic and medical data were recorded and patients' knowledge of COPD was assessed using a 65-item Malay version of Bristol COPD Knowledge Questionnaire (M-BCKQ). M-BCKQ assessed the patients' knowledge about epidemiology and physiology, aetiology, common symptoms, breathlessness, phlegm, chest infections, exercise, smoking, immunization, inhaled bronchodilators, antibiotics, oral steroids and inhaled steroids. Based on answer scheme, 1 score was given for the correct answer and 0 for wrong answer. The highest possible score was 65. Results: Of the 110 enrolled COPD patients, 52.7% (n = 58) patients possessed poor (score < 32.50) knowledge and 47.3% (n = 52) patients had moderate level (score = 32.50-48.75) of knowledge. More than half of the enrolled patients were responded correctly about six main domains of the COPD knowledge including common symptoms (76.4%), phlegm (73.8%), aetiology (67.5%), chest infections (65.1%), breathlessness (56.5%) and oral steroids (56.2%). Conversely, patients responded poorly in the domains of inhaled bronchodilators (26.5%) and immunization (16.2%). Conclusions: None of the patients from study sample possessed good level of knowledge of COPD. There are the significant gaps in COPD patients' knowledge about their illness and respective management. The results of the present study should alert to the healthcare policy makers and administrators to the need for interventions aimed at increasing the knowledge of COPD patients and thus ensuring the better management of COPD. Background and Aims: Recently, blood eosinophil has been emphasized as a candidate biomarker related to acute exacerbation and therapeutic response to inhaled corticosteroids (ICS) in COPD. However, the role of blood eosinophil might be overestimated by including patients with Asthma-COPD overlap syndrome (ACOS). We investigated the clinical impact of blood eosinophil in patients with non-ACOS COPD. Methods: From the Korean COPD Subtype Study (KOCOSS) ongoing cohort including 1421 patients with COPD, we excluded patients with ACOS defined with Spanish ACOS criteria and analyzed blood cell counts, the epidemiologic and spirometric data, and events of COPD exacerbations. In non-ACOS COPD, clinical outcomes including dyspnea, quality of life (QoL), moderate to severe exacerbation of COPD (AECOPD) and the decline of lung function were compared according to the quartiles of the blood eosinophil count and percent. Results: Excluding 667 patients (46.9%) defined with Spanish criteria of ACOS, 754 patients with non-ACOS COPD (53.1%) were finally analyzed. Median values of eosinophil percent and count were 2.4% (0-25) and 168 eosinophils/uL (0-2212). Total white blood cell count and neutrophil percent were inversely correlated with eosinophil percent. (p < 0.001) SGRQ, CAT score, FEV 1 , and the frequency of AECOPD was not associated with blood eosinophil percent and count (p >0.05). Even in multivariate logistic regression analysis adjusting for age, sex, the use of ICS, an eosinophil count and percent were not a significant risk factor for the decline of FEV 1 and the frequency of AECOPD for 1year (p >0.05). Conclusions: In patient with non-ACOS COPD, blood eosinophil was not associated with symptoms, QoL, and FEV 1 and it was not a risk factor for the decline of FEV 1 and AECOPD. The role of blood eosinophil may be limited and it should not be overestimated as a biomarker in patients with non-ACOS COPD. Background and Aims: For 5 years, on World COPD Day, Romania is running COPD awareness campaigns, offering free spirometry for general public. In 2015, we conducted 2 days campaign in Bucharest, using case finding approach: questionnaire plus free spirometry. Methods: Questionnaire has 7 questions and addresses different issues, like possible suggestive symptoms, risk factors (smoking), previous respiratory function investigations (spirometries) and existence of any respiratory therapy. Statistical analysis has been done using Microsoft Office Excel 2007. Results: A lot of 683 persons with mean age = 62.66 AE 14.38 years were screened by spirometry, of which 160(23.4%) had lung function impairment with mean FEV 1 = 62.45 AE 13.73%. Males represented 56.2%(384); 28.1%(192) cases were between 41-60 years and 63.8%(436) had over 61 years old; 51%(348) had respiratory symptoms. From symptomatics ones, 46.8%(163) had dyspnea, 55.1%(192) indicated cough, 34%(118) had chest tightness, 43.1%(150) had wheezing and 6.3%(22) accused all the above symptoms. Although 51 cases had a history of obstructive disease, only 38 of them had spirometry in the last 6 month. Questionnaire analysis revealed that 20.2%(138) previously undiagnosed patients were detected with lung impairment, 31.7%(217) were symptomatic with normal spirometry. Severity disease: 59.8%(409) cases experienced an exacerbation/year, of which 179 had at least 2 exacerbations/year, 144 received antibiotic treatment, 29 were presented to the emergency room and only 9 cases required hospitalization. Conclusions: In Romania, due to COPD awareness campaigns, addressability and accessibility to spirometry increases from year to year. However treating COPD remains deficitary, just 54.2%(13/24) in 2014 and respectively 72.5%(37/51) in 2015 patients known as diagnosed with obstructive disorder being actually treated. COPD awareness campaigns (questionnaires plus spirometry) were usefully for detecting new cases and already undertreated diagnosed cases. Kobe University Graduate School of Health Sciences, Department of Community Health Sciences, Kobe-Hyogo, Japan, 2 Home-Visit Nursing Station Wakakusa, Home Visit Nursing, Nagano, Japan, and 3 National Hospital Organization Higashi Nagano Hospital, Department of Respiretory Medicine, Nagano, Japan Background and Aims: Most of the chronic obstructive pulmonary disease (COPD) patients become malnourished, and weight loss is considered to be an independent prognostic factor in them. We have been providing a home-visit nursing intervention program to COPD patients after the completion of their pulmonary rehabilitation. This study aimed to evaluate the effects of longitudinal changes in the percentage ideal body weight (%IBW) in COPD patients receiving home-visit nursing. Methods: The subjects comprised 45 COPD patients who were followed for 3 years from among all the patients receiving home-visit nursing between 2004 and 2015. We used age, %IBW, lung function, arterial blood gas, activities of daily living (ADL) score, 6-minute walking distance (6MWD), and the Chronic Respiratory Disease Questionnaire (CRQ) as parameters in this evaluation. We calculated the regression line by %IBW of each year; furthermore, we defined increase in %IBW as a regression line slope ≥ 0 (group A, n = 31), and decrease in %IBW as a regression line slope < 0 (group B, n = 14). We compared the results of measurements between the two groups. Results: At the baseline, group A had significantly lower %IBW than group B; however, there were no significantly differences in the other measurements between the two groups. In the first and third years, group A had significantly higher CRQ Total scores than group B.In the third year, both groups had significantly lower ADL scores than those at the baseline, and both groups had significantly lower 6MWD than that in the first year.In the third year, only group A had significantly higher CRQ Total, CRQ Emotional and CRQ Mastery scores than those at the baseline. Conclusions: Functional decline and activity restrictions occur because of illness and aging; however, this study suggested that long-term nutrition management through home-visit nursing helps maintain a high quality of life in COPD patients. Fukuseikai Hospital, respiratory medicine, Fukuoka, Japan, 5 Nishi Fukuoka Hospital, Nursing, Fukuoka, Japan, and 6 Hiroshima University, Graduate School of Biomedical and Health Sciences, Hiroshima, Japan Background and Aims: This research was conducted with the aim of clarifying the characteristics of COPD patients in each disease stage and appropriate preventive behavior against respiratory infection. Methods: Subjects were 82 COPD patients who visited the Department of Respiratory Medicine in three medical facilities including a university hospital in Fukuoka city from November 2014 to June 2015.We acquired basic information on subjects from their medical records, conducted the COPD Assessment Test (CAT), and used self-administered survey sheets on respiratory infection prepared by researchers. This research was conducted with approval of the Clinical Research Support Committee, Fukuoka University Hospital. Results: Subjects were 68 males (82.9%) and 14 females (17.1%). 56 subjects (68.3%) were 70 years and over. The number of patients with stages I, II, III, and IV were 17 (20.7%), 31 (37.8%), 22 (26.9%), and 12 (14.6%), respectively. Body Mass Index (BMI), %Average Level of Vital Capacity, and Forced Expiratory Volume in One Second declined as the disease stage progressed. The average age was in the 70s across all stages of subjects, but the average age of subjects at the stage IV was 59 years at the time of being diagnosed as COPD. The CAT score showed a significant difference between stage I (10 points) and stage IV (20 points). There was no significant difference on preventive behavior against respiratory infection across each stage. Six subjects (50%) in stage IV have been smoking. Conclusions: Patients in stage IV were diagnosed as COPD at the average age of 59, therefore, their duration of illness was long, necessitating lengthy self-management. It would also be considered that patients in stage IV have advanced their disease because 50% of them continued to smoke. Lack of knowledge on the disease might also prevent them from engaging in preventive behaviors on respiratory infection. Background and Aims: Chronic obstructive pulmonary disease (COPD) has a great impact on the quality of life (QoL); however, the evaluation of QoL is lacking in the northern Thailand due to the complexity of the questionnaire and the difficulty in communication especially the minority and elderly people. BODE index is used to predict long term outcomes. Our aim of the study is to find out the correlation between the BODE index and QoL. Methods: A cross-sectional study was conducted in 176 COPD patients in Chiang Dao district, Chiang Mai, Thailand. All patients were assessed QoL by Thai version of St. George's Respiratory Questionnaire (SGRQ). The association between BODE index including each components and SGRQ was evaluated by Pearson correlation and the between BODE quartiles and SGRQ was evaluated by Spearman correlation. Results: The baseline characteristics showed mean age of 69.1 + 10.1 years, male 50.6% and mean postbronchodilator FEV 1 of 60.4+ 29.8%predicted. BODE quartiles were moderately associated with total SGRQ score (r = 0.459, p < 0.01) and all SGRQ subscales (symptom, activity, impact). Each components of BODE index was not better correlated with SGRQ than the sum of BODE index except mMRC (r = 0.655, p < 0.01). Conclusions: BODE index could be the better marker of the QoL among our COPD patients than body mass index, lung function or exercise capacity. Background and Aims: Little is known about the effect of productive cough on outcomes in patients with chronic obstructive pulmonary disease (COPD). We aimed to assess baseline characteristics and outcomes (mortality, exacerbations and cardiac events) in patients with or without productive cough at baseline, and who received tiotropium maintenance therapy, from the TIOtropium Safety and Performance In Respimat ® (TIOSPIR ® ) trial. Methods: TIOSPIR ® (N = 17,135) was a randomized, long-term (2-3years) trial comparing tiotropium Respimat ® 5 or 2.5 μg with tiotropium HandiHaler ® 18 μg. Based on the similar efficacy and safety results in the primary analysis, treatment arms were pooled. Patients were classified by presence of baseline productive cough; hazard ratios and 95% confidence intervals were calculated for time to event using a Cox regression model. Results: Overall, 17,105 patients were classified by baseline productive cough (yes: n = 10,886; 64%). Baseline characteristics and concomitant medications were mostly similar, however, patients with productive cough were more likely to be current smokers, to have had an exacerbation in the last year and they had slightly worse lung function than patients without productive cough (Table 1) . Having productive cough at baseline was not associated with a higher risk of death ( Figure 1 ). Patients with productive cough had a similar risk of moderate-to-severe exacerbations versus those without productive cough, but their risk of severe exacerbations (requiring hospitalization) was significantly increased ( Figure 1 ). The risk of major adverse cardiovascular events (MACE) and fatal MACE was independent from baseline productive cough ( Figure 1 ). Presence of productive cough may be an indicator of a higher risk of severe exacerbations in patients with COPD receiving bronchodilator maintenance therapy. However, productive cough was not associated with increased risk of death, moderate-to-severe exacerbations or cardiovascular events. Acknowledgements:: Editorial and writing support was provided by Jennifer Fuchs of PAREXEL, funded by Boehringer Ingelheim. Background and Aims: Primitive Neuro Ectodermal Tumor (PNET) of the lung was an infrequent case in elderly people. The rare incidence of this tumor causing diagnostic pitfalls. Biopsy continued with imunohistochemistry examination were the standard test to confirm the diagnosis Methods: Presenting a case of 59-year-old women with chief complain cough accompanied by chest pain since 2 months before admitted to hospital. Thoracic CT with contrast showed contrast-enhancing solid mass in posterior segment of left lung superior lobe. FNAB (fine needle aspiration biopsy) CT guiding was performed to obtain the pathology diagnosis.The first FNAB CT Guiding result was adenocarcinoma of the lung. The diagnosis was still uncertain then the second FNAB CT guiding was performed and the result was malignant round cell tumor with some differential diagnosis. Results: Immunohistochemistry result which positive to Vimetin antibody confirming PNET as the definitive diagnosis in this patient. Left lung pneumectomy was performed and adjuvant chemotherapy was planned yet. The patient died within 7 months after being diagnosed due to rapid aggressive progression of the tumor Conclusions: This case illustrates that PNET was an infrequent case with aggressive clinical characteristic and poor outcomes that need prompt diagnosis and treatment Background and Aims: Multiple primary malignancies make up approximately 5.5%-8.5% of all carcinoma cases in the literature. Second primary tumors might develop after treatment of the first primary tumor and might reflect underlying genetic or immunologic defects in the patient, treatment-related damage, or environmental exposure to carcinogens Methods: Presenting a case of 27-year-old woman with malignant teratoma in anterior mediastinum and lung squamous cell carcinoma. Thoracic CT with contrast showed anterior mediastinal mass and mass in lingular segment of left lung. FNAB CT guiding result from mediastinal mass was malignant teratoma (dysgerminoma). Two cycles of BEP (Bleomycin-Etoposide-Cisplatin) regiment chemotherapy and 2 cycles of radiotherapy was done resulting in complete resolution of mediastinal mass. Wedge resection of mass in lingular segment was done and postsurgery tissue pathology result was poorly differentiated squamous cell carcinoma of the lung Results: PET Scan result showed metastatic nodul in liver. Platinumbased chemotherapy was given and evaluation of thoracic CT showed good result Conclusions: This case illustrates multiple primary malignancies involving anterior mediastinal and lung mass. Early diagnosis and modern chemotherapy/radiation therapy have improved survival rates, and longterm remission of patients with cancer now allows more patients with neoplastic disease to survive long enough to develop subsequent primary tumors Background and Aims: Thymomas are mediastinal primary tumour of the mediastinum and associated with a variety of autoimmune disorders often linked to T-cell mediated autoimmunity. Paraneoplastic pemphigus (PNP) is an immunologically mediated skin disease characterized by epidermal blisters that may occurin association with thymic or non thymic neoplasms Methods: 21 years old man came to the hospital with vesicles and ulcus at whole body since 3 weeks before. Patient was diagnosed with Pemphigus vulgaris and thymomas since 2 years. Patient was hospitalized for 3 times with same cases. Patient underwent chemotherapy Carboplatin-Etoposide 6 series and no response had been documented. Patient was suggested to undergo a resection of thymoma to prevent the exacerbation of pemphigus but he refused. The medication given was only aimed for reducing the exacerbation of Pemphigus Results: PNP is characterized by the production of autoantibodies against various target antigens, mainly plakin family proteins and desmogleins. PNP results from an antitumor immune response cross-reacting with the normal epithelial proteins and thereby inducing autoimmunity by molecular mimicry. PNP sera bind to homologous region within carboxyterminus of members of the plakin gene family.There are also involvement of dysregulation of T-cell development Conclusions: Pemphigus is rarely associated with Thymomas, but the fact there is an association between Thymomas and pemphigus. According to this fact, every patients with pemphigus should be suspected with malignancies especially thymomas until it was ruled out Background and Aims: To observe the proliferation of lung cancer cell line A549 by RNAi,in order to provide a basis for the treatment of lung cancer. Methods: The SiRNA-HMGN5 lentivirus particles were infected into A549 cells, in order to silence the expression of HMGN5. The interfering efficiencies of the plasmids on HMGN5 gene were detected by RT-PCR and Western blotting methods. We analyzed the proliferation and cell cycle on A549 by MTT assay. Results: The mRNA level of HMGN5 gene could be down-regulated. SiRNA-HMGN5-lentivirus inhibited the proliferation of A549 cells with statistically significant difference by MTT assay. Conclusions: The proliferation of A549 cells can be inhibited by silencing HMGN5 gene. HMGN5 gene may play a role in the development of lung cancer and it may be beneficial for the cure of lung cancer. Dharmais Cancer Hospital, General Practitioner, Jakarta Barat, Indonesia, and 2 Dharmais Cancer Hospital, Respiratory Medicine, Jakarta Barat, Indonesia Background and Aims: Malignant Pleural Effusion (MPE) in is a sign of advanced stage in lung cancer.The frequency of MPE in lung cancer is 7-23% and it is related with poor prognosis. Five years survival in advanced stage lung cancer is about 4%. Our study aimed to identify prognostic factors and survival time in patients with MPE in lung cancer. Methods: A retropective study was held in Dharmais National Cancer Hospital between January -December 2015. The prognostic factors such as sex, age, stage (IVA and IVB), and therapy analysed by the Kaplan-Meier technique were compared using the log-rank test. The cox regression method was used to determine several prognostic factors with respect to survival time. Results: Three-hundred and forty-three patients were included in this study; 229 men (66.7%) and 114 women (33.3%). Median age was 60 years old (range 20 to 88 years old). Of 343 patients, 128 patients were died (37.3%) and 191 patients had systemic therapy (55.6%). The median overall survival of patients was 427 days (range: 299.4 to 554.5 days). Kaplan-Meier univariate analysis showed that survival was significantly related to stage (Hazard Ratio (HR) 2.32, 95% confidence interval (95%CI) 1.62 to 3.33, p < 0.00001) and therapy (HR 0.19, 95%CI 0.12 to 0.28,p < 0.00001). Other prognostic factors that were examined did not appear to affect overall survival (sex; p = 0.90 and age; p = 0.233). Background and Aims: Sleep-related breathing disorder (SRBD) is known to be a significant but underdiagnosed cause of morbidity in children. Clinical presentations include snoring, nocturnal arousals, restlessness during sleep, enuresis, daytime sleepiness and hyperactivity. Methods to help identify SRBD without the expense of the gold standard for diagnosis, which is the overnight polysomnography, could greatly facilitate clinical and epidemiological research. A screening tool that is culturally appropriate and linguistically accessible instrument among Filipinos for the assessment of sleep quality in children is of great value. The aim of this study was to culturally validate the Filipino version of the SRBD subscale within the pediatric sleep questionnaire (PSQ). Methods: The SRBD subscale within the PSQ was forward translated to Filipino, synthesized and back-translated to an English version. A panel of experts reviewed the pre-final Filipino version and pilot-testing was done. Validation of the final version was done. Results: A total of 300 parents/ caregivers of children of varying age groups were included in the study. Results showed that the Filipino version of the SRBD subscale within the PSQ was accurate, reliable and internally consistent. Reliability analysis yielded an overall Cronbach α of 0.882, confirming the questionnaire's consistency. The Cronbach α of the Filipino SRBD subscale within the PSQ ranged between 0.62-0.87. The test-retest reliability for all items was robust with correctness of >95% in all items, and the Kappa statistic ranged between 0.98-1.0. Conclusions: The Filipino version of the SRBD subscale within the PSQ has sufficient reliability and validity to measure sleep disordered breathing outcomes. It is as effective as the original English version. Background and Aims: Idiopathic pulmonary fibrosis (IPF) involves alveolar epithelial injury and abnormal collagen production. Lung myofibroblasts produce considerable amounts of extracellular matrix components like collagen, which may give rise to abnormal fibrosis. Transforming growth factor (TGF)-β1 appears to stimulate both activation of fibroblasts into myofibroblasts and collagen synthesis. Thus, chemicals capable of suppressing TGF-β1-induced production of collagen represent good candidates to treat IPF patients. In this study, we screened for chemicals capable of inhibiting TGF-β1-induced collagen production in cultured fibroblasts from medicines already in clinical use. Methods: Collagen levels in culture medium were determined by Sircol assay. The severity of the pulmonary fibrosis was assessed based on histopathologic evaluation, lung mechanics and respiratory function. Results: We selected felodipine based on its extent of collagen production inhibition, clinical safety profile, and other pharmacological activity. Felodipine is a Ca 2+ channel blocker that has been used clinically to treat patients with high blood pressure. Felodipine suppressed collagen production within LL29 cells (Lung fibroblasts from an IPF patient) in the presence of TGF-β1, but not in its absence. Intratracheal administration of felodipine prevented bleomycin-induced pulmonary fibrosis, alteration of lung mechanics and respiratory dysfunction. Felodipine also improved pulmonary fibrosis, as well as lung and respiratory function when administered after fibrosis development. Furthermore, administration of felodipine suppressed a bleomycin-induced increase in activated fibroblasts in the lung. We also found other Ca 2+ channel blockers (nifedipine and benidipine) inhibited collagen production in vitro and also prevented bleomycininduced pulmonary fibrosis, alteration in lung mechanics and respiratory dysfunction in vivo. Conclusions: These results suggest felodipine inhibits bleomycininduced fibrosis through blockade of Ca 2+ channel activity. We propose felodipine may be therapeutically beneficial for IPF patients. Background and Aims: Intermittent hypoxia (IH), one of the important pathophysiological components in sleep apnea, has been reported to produce weight loss in animals. However, sleep apnea conversely induces weight gain when not properly treated. To better understand this apparently paradoxical effect of IH on body weight, we intended to analyze the effect of IH on body weight excluding the influence of food intake. Methods: We exposed C57BL/6J female mice (n = 8, 8-10 weeks old) to 16 hours of IH alternating hypoxia of 10-11% and normoxia, or sham intermittent hypoxia (SIH, n = 8) without food. After getting out of the IH (or SIH) chamber, mice were given high-fat diet. Results: The increase in body weight in IH group was significantly more than SIH group between 5 to 21 days after the start of IH (p < 0.05, unpaired t-test). At 1 month after the start of IH, IH (16 hours, without food) was loaded again to IH group, and then the statistical significance reappeared. Consumed food weight in IH group was more than SIH group. Conclusions: IH without food caused more body weight gain in mice than SIH with reproducibility. IH does not always produce weight loss in mice. IH may be the pathophysiological factor to increase body weight in sleep apnea, and it may worsen sleep apnea thus causing the vicious cycle. Background and Aims: Previous reports regarding sleep disorder in allergic diseases including asthma are limited. Sleep disorder is known to cause fatigue and daytime sleepiness and may worsen asthma control and quality of life. Moreover it increases the risk of various diseases such as hypertension, diabetes and cardiovascular disease. Although sleep disorder is considered one of high risk factor for systemic inflammation, the association of sleep disorder with asthma is not fully clarified. Furthermore, both asthma and obstructive sleep apnea (OSA) are common diseases and may coexist. However, the prevalence of OSA in asthmatics is not well documented. Therefore, we focused on the association between asthma and OSA utilizing screening questionnaires. Methods: Study participants enrolled in this study consist of asthma patients who regularly visited Saitama medical university hospital. Screening questionnaires included a physique, Asthma Control Test (ACT), Pittsburgh Sleep Quality Index (PSQI), Berlin questionnaire, Epworth Sleepiness Scale (ESS), and Hospital Anxiety and Depression scale (HADs). Sleep study was carried out in asthma patients suspicious of OSA by these questionnaires (n = 7). Results: A total of 89 patients with asthma were divided into 2 groups (39 suspicious of OSA, 50 not suspicious). There were significant differences in ACT, PSQI, Berlin questionnaire, ESS, and HADs between the groups. Furthermore, about 70% in asthmatics suspicious of OSA (n = 5) were treated with CPAP after the sleep study. Conclusions: Our results demonstrated high prevalence of sleep apnea in patients with asthma. Multiple questionnaires may be useful to screen sleep apnea in patients with asthma. Background and Aims: Obstructive sleep apnea syndrome (OSAS) is a common disorder and is associated with impaired quality of life, increased risks of motor vehicle accidents and cardiovascular diseases. Continuous positive airway pressure (CPAP) therapy is widely used for the treatment of OSAS. However, about 20% of the patients will discontinue the CPAP therapy at an early stage. To determine whether the education system based on the CPAP adherence tracking system can reduce early discontinuation from the CPAP therapy in patients with OSAS. Methods: The patients with OSAS who started CPAP during 2007 to 2016 were divided into two groups (good adherents; at least 4 hours/night on 70% of nights during a consecutive 30-day period, poor adherents; other than those above) using the adherence tracking system. Furthermore, poor adherents were classified into two patterns by average dairy usage time in using days (short period user; less than 4 hours/night, infrequent-long period user; more than 4 hours/night). A new education system that conforms to the pattern of poor adherence group was started in 2013 (short period user: do not have to use every day, but use as long as possible when you use it, infrequent-long period user: increase the number of using days). Results: 282 patients started CPAP therapy. Lack of daytime symptoms was significantly higher in poor adherents. Monthly average usage time of CPAP was similar in short period users and infrequent-long period users, whereas the dropout rate was significantly higher in short period users. After the new education system introduced, dropout rate was significantly reduced (20.6% to 8.3%, p < 0.05). Conclusions: Short period usage of CPAP may be a predictive factor for the early discontinuation of the therapy. Using the educational contents which adapts to the patterns of poor adherents may be useful to improve the continuity of CPAP therapy in patients with OSAS. Background and Aims: It is well known that indigenous people have very high risk of developing chronic medical conditions such as Cardiovascular, Respiratory, Diabetes and Renal diseases contributing to higher morbidity/mortality in this population. Sleep disordered breathing/obstructive sleep apnoea is known to contribute to adverse health consequences in non-indigenous population all around the world. However there is no published data on the prevalence of obstructive sleep in indigenous population, especially in Australian aboriginal people, were indigenous people make up for 12.5% of the national Indigenous population, of them 81% live in remote communities. Methods: This is a retrospective study involving only people of indigenous origin in the Northern territory of Australia over a 4 years period who have undergone a diagnostic sleep study on a clinical diagnosis of obstructive sleep apnoea. Demographic, clinical characteristic, presence of other medical co-morbid conditions and polysomnography (PSG) data was examined for several sleep parameters, including presence and severity of sleep apnoea. Results: The results of the study will be discussed at the conference (data is still being analysed) Conclusions: Interim analysis of the data suggest that there may be significantly high prevalence of sleep disordered breathing/obstructive sleep apnoea in indigenous population in addition to presence of other significant medical co-morbid conditions, which (OSA) may be contributing to adverse health consequences. Background and Aims: Sleep disordered breathing (SDB) was reported in acute decompensated heart failure (ADHF) patients. Expedited treatment of SDB during transition period may have potential benefit on heart failure outcomes. However standard in-laboratory polysomnography (PSG) had limitation given such critical condition. Objective: To compare performance of cardiopulmonary monitoring (type 3) and unattended PSG (type 2) in diagnosis of SDB during ADHF. Methods: Study design: A cross-sectional study. Population and Methods: Patients hospitalized from ADHF, aged 18-80 years were recruited in Ramathibodi hospital. Both PSG type 2 and 3 were performed on consecutive nights. Results: Seventeen subjects (7 males) with mean age and body mass index of 66.2 AE 14.5 years and 26.6 AE 5.6 kg/m2 were included. Left ventricular ejection fraction ranged from 20-77% [mean AE SD, 48 AE 20.6%]. All patients had SDB [cut-off apnea-hypopnea index (AHI) ≥ 5] and 76.5% of patients had AHI ≥ 15. Apnea-hypopnea index was lower in type 3 monitoring than PSG type 2 [median (IQR): 28.7 (9.9-43.2) versus 41.3 (20.5-50)], despite good correlation(r = 0.81, p < 0.001). Compared to PSG type 2, type 3 cardiopulmonary monitoring had sensitivity, specificity, and area under the ROC curve (AUC) for diagnosis of SDB and OSA (cut-off AHI ≥ 15) of 0.76, 1.00, and 0.88, respectively and 0.66, 1.00 and 0.83, respectively Conclusions: Sleep disordered breathing was highly prevalent in ADHF patients with majority in moderate to severe severity. Both PSG type 2 and 3 were feasible during ADHF. Even type 3 monitoring showed good performance with high specificity. Screening for SDB during ADHF may have potential role for improvement of current heart failure treatment. Background and Aims: Obstructive sleep apnea syndrome (OSAS) is related to narrowing airway. The forced oscillation technique (FOT) is a noninvasive method to evaluate resistance and reactance in airway system. Methods: We examined the respiratory resistances of 8 patients with OSAS during awakening in the sitting, supine, and left lateral recumbent positions using the MostGraph-01 FOT instrument. Results: We observed a significant correlation between the apneahypopnea index (AHI) and respiratory resistance at 20 Hz (R20), a predictive index of upper airway's resistance, in each the sitting (r = 0.671, p < 0.01), supine (r = 0.681, p < 0.05), and left lateral recumbent positions (r = 0.675, p < 0.05). Conclusions: FOT might be a useful technique to estimate the pathophysiology and severity of OSAS. Background and Aims: Sleep problems are common and cause significant disruption in quality of life in chronic pulmonary disease (COPD) patients, but there is little data about the impact of sleep quality on quality of life in patients with COPD in Korea. The purpose of this study was to determine association between obstructive sleep apnea (OSA) with sleep quality and quality of life in COPD patients. Methods: Two hundred patients (93% men) with mild to severe COPD were enrolled prospectively. All patients were evaluated by pulmonary function test for determination of severity of COPD (mild 55; moderate 111; severe 34). The Modified Medical Research Council Scale, Berlin questionnaire, Pittsburgh Sleep Quality Index (PSQI), and St. George Respiratory Questionnaire (SGRQ) were employed for assessment of patients. Results: Sixty-two (31%) patients were at high risk for OSA. Eighty-two (41%) patients showed poor quality of sleep. The patients with OSA and COPD had worse quality of sleep compared to COPD without OSA (PSQI 6.9 AE 4.1 versus 5.4 AE 3.1, p = 0.01). Quality of life in COPD patients was significantly correlated with quality of sleep (r = 0.376; P < 0.001), post-bronchodilator FEV1% predicted (r = -0.424; p < 0.001), and severity of dyspnea (r = 0.360; P < 0.001). Conclusions: OSA is common in patients with COPD. Sleep quality is also poor among this group. Quality of life in COPD patients was associated with sleep quality, underlying lung function, and the degree of dyspnea. It is recommended that more adequate attention is needed to manage the sleep problem of COPD patients. Background and Aims: To investigate the utilization of a smart phone application (Wechat) on the follow up of obstructive sleep apneahypopnea syndrome (OSAHS) children. Methods: We recruited 80 cases of OSAHS children, randomly divided them into Wechat group and traditional telephone group to follow up. These patients are follow up monthly for three month. And we collect lost follow up rate, compliance, patient satisfaction, follow-up work time and the complete degree of patient data collection. Results: The Wechat group is significantly lower than the other group on lost follow up rate, higher on compliance, patient satisfaction and health knowledge scores, decreased on the follow up work time (P < 0.01). Conclusions: Utilization the Wechat smart phone based application to follow up the OSAHS children is feasible. It can significantly decrease the lost follow up rate, increase the compliance, patient satisfaction, follow up work efficiency, and greatly improve the integrity of the collection of medical data. Introduction: Narcolepsy is characterized by a tetrad of excessive daytime sleepiness, cataplexy, hypnogogic hallucinations and sleep paralysis. There are similarities in symptomatology of narcolepsy across different ethno-cultural backgrounds. However meaning given to narcolepsy and its aetiological interpretation is ethno-culturally determined. These factors also influence patients' reaction to the symptoms and willingness to seek medical attention Here we present a case of narcolepsy with cataplexy experienced by a clergyman in Malaysia. He presented with debilitating sleep attack episodes while giving sermons and religious lectures. He also had few episodes of continuous uninterrupted sleep up to 3 days. He attributed these episodes as supernatural events. Polysomnography study and multiple sleep latency tests confirmed the diagnosis of narcolepsy. However, patient doubted the diagnosis and declined medical treatment. Discussion: In this case we describe a difficult-to-treat patient who doubts the diagnosis and treatment of narcolepsy despite diagnosis by multiple sleep latency test and polysomnography study. This highlights the vital role of understanding local ethno-cultural backgrounds in the process of narcolepsy management in Malaysia. Background and Aims: Sleep discrepancy is the differences between subjective and objective measures of sleep which is known to be observed in patients with paradoxical insomnia. Theoretically, obstructive sleep apnea (OSA) patients may also exhibit sleep discrepancy due to sleep disruption. In this study we want to determine the discrepancy between subjective and objective sleep parameters in OSA. Methods: Patients diagnosed with OSA from July 2014 till July 2015 at Excellence Center for Sleep Disorders at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, age more than 18 years old were included in this retrospective study. Patients who had other sleep disorder besides OSA including periodic limb movement disorders, insomnia, sleep bruxism, and parasomnia were excluded from the study Results: Total of 514 patients were included in this study. The baseline demographic data showed that the sample population was 58.4% male with mean age of 52.6 AE 15.5 years. The mean Epworth sleepiness scale score was 10.0 AE 4.9 and the mean apnea hypopnea index and respiratory disturbance index was 38.8 AE 26.7 and 41.2 AE 25.9; respectively. Paired comparison of self-reported versus polysomnography-reported sleep parameters showed that there were statistically significant difference in mean sleep latency (minutes) 62.5 AE 75.3 vs 13.7 AE 21.5 (p < 0.001), mean total sleep time (minutes) 347.7 AE 97.9 vs 369.4 AE 64.0 (p < 0.001) and mean sleep efficiency (%) 77.9 AE 20.3 vs 83.3 AE 13.1 (p < 0.001). Overall the patient accurately predicted their sleep latency (to be within 30 minutes or not) in 59.1%, their total sleep time (<30 minutes discrepancy) in 31.3%, and their sleep efficiency (to be at least 85% or not) in 63.6%. Conclusions: Our result showed that obstructive sleep apnea patients tend to overestimate their sleep onset latency, underestimate their total sleep time and underestimate their sleep efficiency. Background and Aims: To investigate the effects ofinhaled short-acting bronchodilators on diaphragm function and neural respiratory drive in patients with chronic obstructive pulmonary disease (COPD) during maximal isocapnic ventilation (MIV). Methods: Forty-seven moderate-to-severe COPD patients were randomized into four groups: placebo group (n = 12), salbutamol group (n = 13), ipratropium group (n = 10) and combined group (salbutamol and ipratropium, n = 12). Each subject initially performed MIV for three minutes at baseline, and then repeated 3-min MIV 30 minutes after inhaled placebo 400μg, or salbutamol 400μg, or ipratropium 80μg, or combined inhalation of salbutamol 400μg and ipratropium 80μg, based on the group. The parameters of diaphragm function and neural respiratory drive were monitored continuously and calculated during MIV. Results: During MIV, all groups experienced a linear increase in root mean square (RMS) of diaphragm electromyogram but showed gradual decrease intransdiaphragmatic pressure (Pdi), minute ventilation (VE) and VE/RMS. After inhalation of the bronchodilators, the parameters of salbutamol group, ipratropium group and combined group improved significantly. In comparison with placebo group, the values of RMS and Borg score in the other groups at the same time point decreased significantly, and those of Pdi, VE and VE/RMS increased significantly. In comparison with monotherapy groups, combined group had greater VE/RMS (P < 0.05). The △Borg was significantly correlated with △Pdi, △VE, △RMS, and △VE/RMS, respectively (all P < 0.05). Conclusions: Inhaled short-acting bronchodilators can alleviate the diaphragm fatigue of COPD patients during MIV, increase lung ventilation, reduce neural respiratory drive, and improve neuro-ventilatory coupling, which might underlie the reduction of dyspnoea in COPD patients. Moreover, a combination of β-2 agonists and anti-muscarinic antagonists showed superior efficacy. Background and Aims: Pulmonary crystal-storing histiocytosis (CSH) is a rare condition associated with lymphoproliferative and plasma cell disorder. To date, there is little information available regarding treatment and prognosis of pulmonary CSH. Methods: A 63-year-old woman presented with fever, productive cough and consolidation at right lower lobe, which initially had been diagnosed of community-acquired pneumonia. She also had pancytopenia and acute kidney injury. After an investigation, the diagnosed of multiple myeloma was made. Her Chest X-ray showed progressive pulmonary infiltrations despite a course of antibiotic. Bronchoscopy was performed, and transbronchial lung biopsy showed intraalveolar mononuclear cells containing abundant of eosinophilic cytoplasmic microglobules without any organisms. Pulmonary CSH was diagnosed. Two weeks after a course of dexamethasone treatment, her chest X-ray was almost clear. Results: Multiple myeloma has various forms of pulmonary involvement. Thoracic skeletal involvement is the most common site (about 28%) whereas parenchymal infiltration is found in only 10%, and almost all are pneumonia. Crystal-storing histiocytosis is a rare finding characterized by histiocytes with an accumulation of intracytoplasmic immunoglobulin crystals. 90% of CSH have an underlying lymphoproliferative/plasma cell disorder. This disease can involve various sites and can occur as a localized form or generalized form. Lung and pleura are the second most common site of localized CSH (24%). In case series, patients with pulmonary CSH usually presented with single or multiple pulmonary nodules. The diagnosis is based on pathological findings and exclusion of other macrophage-rich conditions. To date, there is little information available according to treatment and prognosis of pulmonary CSH. Conclusions: Pulmonary CSH is one of the rare lung parenchymal involvements in multiple myeloma, which has several manifestations. The mainstay of management of this condition is the treatment of the underlying condition. Background and Aims: Desquamative interstitial pneumonia is among the myriads of a scarce subcategory of idiopathic interstitial lung disease. Predisposition factor appears to be related to tobacco in more than 90% of cases. Age of onset is around 40 to 50 with male preponderance. We report a case of multiple admissions for pneumonia which was later found to be biopsy-proven desquamative interstitial pneumonitis. Case Description A 68 years old male smoker, with backgrounds of diabetes, hypertension, chronic kidney disease and ischemic heart disease, presented to us with relapses of fever and dyspnoea. This has occurred over a period of six months. Multiple antibiotic exposures including those of carbapenem group (meropenem) and antifungal (fluconazole). Chest radiography revealed right lower zone pleural effusion which was exudative in nature. Cytology was negative. Bronchoscopy was inconclusive. Thoracic computed tomography (CT) demonstrated right upper and lower zone consolidation with peripheral ground glass opacity and air bronchogram. No evidence of malignancy was found in such imaging. CT guided lung biopsy was consistent with desquamative interstitial pneumonitis. Steroid was subsequently commenced with smoking cessation. At the time of submission, good clinical response was attained and he was doing well. Conclusions: Such rare entity has generally been considered to have better outcome than the other subtypes of idiopathic interstitial pneumonia. Thus, prompt identification and treatment initiation are keys to retard progression. Nevertheless, other commoner differentials should be excluded first when encountering patients unresponsive to antibiotic therapy for pneumonia. Background and Aims: Pulmonary alveolar proteinosis is a rare entity of interstitial lung disease. It could often mimic other commoner respiratory conditions at initial stage. We report a pregnant lady from Malaysia with chronic dyspnoea not responding to diuretic or antibiotics whom was diagnosed later with such scarce disease with uneventful delivery. Case description We present a 38 years old lady gravida 3 para 2 at 35 weeks of gestation, with background history of mild intermittent asthma, presented to our clinic with three-month history of shortness of breath and dry cough. Otherwise she was afebrile and no symptom variability during daytime and night time. No associated constitutional symptoms was reported. No risk factors for pulmonary embolism was identified. Clinically she was not in respiratory failure and lungs were clear. Connective tissue screening was negative. She was treated initially with one week of antibiotic course for community acquired pneumonia at private centre. Trial of diuretic was given as well by the centre for presumed mild pulmonary edema due to unresponsiveness to the antibiotic therapy. She delivered uneventfully via elective Caesarean section one week after our visit. Chest radiography showed bilateral hilar ill-defined opacity. Subsequent thoracic computed tomography revealed crazy paving pattern. Bronchoalveolar lavage was positive for Periodic Acid Schiff staining. Whole lung bronchopulmonary lavage was done 3 months post-partum and her symptoms resolved, with improvement both in lung functions and 6-minute walking test. Conclusions: This case highlights another case of pulmonary alveolar proteinosis presenting in pregnancy. However, respiratory function was not compromised and she was able to undergo the lavage during postpartum period. Another point to emphasize here is clinician should always first to consider pneumonia and other commoner respiratory diseases while approaching a pregnant lady with chronic dyspnoea and cough before thinking about such rare entity of pulmonary alveolar proteinosis. Background and Aims Background: Non-cystic fibrosis bronchiectasis is characterized by neutrophil-driven airway inflammation leading to recurrent respiratory infections. Roflumilast is an oral phosphodiesterase 4-inhibitor that decreases neutrophil-driven airway inflammation. We tested the hypothesis that roflumilast decreases the exacerbation frequency in bronchiectasis patients. Objective: The primary endpoint was rate of event-based exacerbations in a 6-month treatment period in two groups. The secondary endpoints were change in FEV 1 before bronchodilator use, change in total score of the St George's respiratory questionnaire (SGRQ) and change in the 6MWT distance in a 6-month period. Methods: Participants were patients diagnosed as bronchiectasis defined by HRCT and had at least one pulmonary exacerbation requiring antibiotic treatment in the past year. We randomly assigned patients to receive 500 mg of roflumilast or placebo once daily for 6 months in a 1:1 ratio. Patients and investigators were masked to treatment allocation. Results: The roflumilast and placebo groups each had 15 patients. The rates of event-based exacerbations were 0.57 per patient and 0.59 per patient in the roflumilast and placebo groups, respectively, in the 6-month treatment period (rate ratio 0.97, p = 0.96). Prebronchodilator FEV 1 increased by 0.07 L from baseline in the roflumilast group and decreased by 0.015 L in the placebo group, but the difference was not significant (0.085 L, 95% CI −0.08 to 0.25, p = 0.28). No significant differences were found in the change of SGRQ total score between the roflumilast (−13.46 units) and placebo groups p = 0.19) . The change in the 6MWT distance did not differ between the roflumilast (21 meters) and placebo groups (22.85 meters; difference −1.85 meters, 95% CI −66.93 to 63.22, p = 0.95). Conclusions: No significant differences were observed in the rate of event-based exacerbations between the bronchiectasis patients who received roflumilast and placebo for 6 months. Background and Aims: Bronchopulmonary sequestration is an uncommon congenital lung malformation which is characterized by a nonfunctioning segment of lung parenchyma without normal connection with the tracheobronchial tree. Methods: We report a case of intralobar sequestration. A 42-year-old male presented at Pham Ngoc Thach (PNT) Hospital with a symptom of mass haemoptysis (300 ml). He had had a long history of dry cough and had been diagnosed with pharyngitis and bronchitis, and treated with antibiotics. Two months before PNT admission, he complained of sputum production, hemoptysis, right chest pain and mild dyspnea. Two weeks ago, he developed mass haemoptysis then he was immediately admitted to PNT Hospital. The patient had an unremarkable physical exam. Chest radiography showed a well-defined consolidation in the lower lobe. Chest CT scan confirmed the features identified on chest radiograph, showing a consolidation with a cavity in it in the right lower lobe. An anomalous artery was noted from the abdominal aorta to have entered the consolidation. Bronchoscopy showed pus coming from right lower lobe. Based on chest radiography and CT scan, we diagnosed the case as intralobar pulmonary sequestration of the right lower lobe. The patient was referred to the surgery department for standard thoracotomy and lobectomy. A right lower lobe resection with ligation of the aberrant artery was performed successfully without complications. Pathologic examination of the resected right lower lobe showed features consistent with intralobar sequestration associated with infection of Actinomyces and haemorrhage. Results: The patient was later discharged in good health on the 15 th postoperative day. Conclusions: The above case illustrates a typical presentation of an intralobar bronchopulmonary sequestration. Pulmonary sequestration should be considered in patients with repeated pulmonary infections, hemoptysis and persistent lower lobe abnormalities on chest radiograph and CT scan. Surgery is a mainstay of treatment with lobectomy and ligation of the aberrant artery. Background and Aims: Hip fracture is an important health care issue in older people. The one year mortality after hip fracture is about 20-35%. Postoperative pulmonary complications occurred 4 % of patients after hip fracture surgery, and about 50 % had severe complications such as pneumonia or respiratory failure. Pulmonary rehabilitation is effective in reducing postoperative pulmonary complications, especially in high risk surgical patients. However, there is no pulmonary rehabilitation focused on the patients after hip surgery. Today, we present a retrospective study about effect of the elderly hip fracture patients who accepted a comprehensive pulmonary rehabilitation program after hip surgery. Methods: We included the elderly patients (older than 65 years old) who developed new hip fracture since 2014/2/1 to 2015/12/1 and willing to accept postoperative pulmonary rehabilitation program. The pulmonary rehabilitation program started after 2015/1/1. The patients who refused rehabilitation or no surgical intervention are excluded. We collected the age, sex, comorbidities, lab data, operation type, operation date, pneumonia date for analysis. Results: There were total 240 patients (163 women and 77 men) with 138 cases in 2014 and 102 cases in 2015. The characteristic of age, sex, comorbidities, lab data, and surgical type reveal no significant difference between patients in 2014 and 2015. In 2014, total 19 patients (13.9%) developed pneumonia, but in 2015, 6 patients (5.9%) diagnosed pneumonia. We found that older than 80 years old, cancer patients and without postoperative pulmonary rehabilitation program had higher risk of pneumonia development. In the multivariate analysis, old age (odds ratio, OR = 4.4), stroke (OR = 4.5) and diabetes patients (OR = 24.8) had higher probability of pneumonia. Conclusions: In older patients of hip fracture after surgery accepted postoperative pulmonary rehabilitation program could decrease pneumonia incidence in our study. This is the first trial to prove postoperative pulmonary rehabilitation program effect in hip surgery patients. Background and Aims: Majority of such incapacity are detected incidentally and treated conservatively. Surgical intervention is seldom required. We highlight this case to emphasize the importance to recognize this entity which can mimic an underlying pneumonia. Methods: We have a 71-year-old woman who was consulted by orthopaedic team on the right lung basal consolidation with the initial impression of orthostatic pneumonia. She had underlying hypertension and presented to the orthopaedic team for lumbar epidural abscess. Drainage was done and the patient was treated with six weeks of intravenous tazobactam/piperacillin. However, diaphragmatic paralysis was demonstrated on chest ultrasonography-diaphragm. Conclusions: The exact occurrence of diaphragmatic paralysis worldwide is still unclear due to its rarity and its asymptomatic nature. Some cases could have been mistakenly treated for pneumonia. Chest ultrasonography appears to be a reasonable diagnostic modality in identifying such condition. Background and Aims: Home mechanical ventilation (HMV) has been shown to improve survival and quality of life in a wide variety of indications. However there is paucity of real world data to guide the optimal timing of initiation of HMV for most indications, and it is unclear if earlier initiation leads to better outcomes. Our aim is to review the impact of acute versus elective initiation of HMV on patient outcome. Methods: We conducted a retrospective analysis of all the patients on HMV at Singapore General Hospital from 1 March 2000 to 30 November 2014 and compared the outcome of acute versus elective initiation of HMV. Results: 160 patients were included (Table 1 ) and all had non-invasive mask ventilation except 7 tracheostomized patients. HMV was initiated in 120 (75%) for acute respiratory failure and electively initiated in 40 (25%). All tracheostomized patients were acutely initiated. HMV indications were similar in both the acute and elective groups. Excluding the tracheostomized patients, the two groups had similar demographics, machine settings and compliance. Electively initiated patients had better continuation rates ( Figure 1 ) and survived longer compared to those who required acute initiation (1-year mortality 5% versus 10.8%, p = 0.045). Conclusions: Our data suggests that patients electively initiated on HMV have improved survival and better continuation rates. The difference could be attributed to timing of HMV initiation, differences in disease severity or lead time bias. More research is needed to determine the optimal timing for HMV initiation. Changi General Hospital, Respiratory and Critical Care Medicine, Singapore, Singapore, and 2 St. Andrews Community Hospital, Nursing, Singapore, Singapore Background and Aims: Massive haemoptysis is an emergency that requires prompt recognition and timely intervention so that airway protection measures can be instituted followed by therapeutic intervention. A review of the literature shows very few studies that evaluate the quantification of haemoptysis by healthcare professionals. Our aim is to evaluate healthcare professionals' definition of massive haemoptysis and their ability to quantify expectorated blood volume accurately. Methods: We conducted a survey on doctors and nurses in Changi General Hospital. Respondents were asked to define massive haemoptysis and to estimate the amount of moulage blood present in 4 sputum cups consisting of 10mls, 30mls, 50mls and 100mls of moulage blood ( Figure 1 ). Results: A total of 101 healthcare professionals were surveyed. Thirteen (12.9%) defined massive haemoptysis as volume of expectorated blood <100mls, 75 (74.2%) defined it as volume of expectorated blood ≥100mls and 13 (12.9%) had incomplete data. Twenty-five (24.7%) estimated the amount of moulage blood as 100-199mls, 33 (32.7%) indicated 200-299mls, 3 (3%) indicated 300-399mls, 0 (0%) indicated 400-499mls and 14 (13.9%) indicated >500mls. Only 4 (3.9%) of respondents accurately identified all the sputum samples of varying quantities and 39 (38.6%) of respondents had none correct while 32 (31.7%), 13 (12.9%), 11 (10.9%) of the respondents had 1, 2 and 3 correct answers respectively with 2 (1%) incomplete answers. Conclusions: There is significant disparity in the definition and estimation of massive haemoptysis amongst healthcare professionals. There is an urgent need for education and training to improve the recognition of massive haemoptysis. Background and Aims: Occult pneumothorax is a radiological pathology that cannot be determined in chest x-ray, but is visualized in computed tomography (CT). Especially in cases with trauma who are candidates for mechanical ventilation, the progression of even a small lesion to tension pneumothorax is an important, life-threatening problem. On the other hand, an early diagnosis is also important in regard to the medico-legal evaluation. CT investigation in thoracic trauma reveals all existing pathologies; however, it is a matter of debate to apply CT in every case regarding the costs, high level of radiation, and the slowing of turnover in the emergency clinic. The current study investigated the clinical and radiological characteristics that accompany cases with occult pneumothorax, in order to determine the indications of thoracic CT in the cases with trauma. Methods: The cases who had thoracic trauma were selected from all cases for whom a medicolegal report was evaluated at a Forensic Medicine Department in three years. The data were obtained from the medical files and medicolegal reports of the patients by retrospectively. Of the 63 cases who were admitted to the emergency clinic with trauma, 47 underwent thoracic CT and pneumothorax was assessed in 14 (29%) cases. Results: It was detected in only four of these cases in the chest x-ray. The ratio of occult pneumothorax was calculated as 10/14 (71%). Blunt trauma, the presence of head trauma, extensive subcutaneous emphysema, and multiple rib fractures were common characteristics of the cases who were detected only with CT. Conclusions: These cases, who have all co-existing pathologies were recommended to be investigated with computed tomography regarding the presence of pneumothorax. Background and Aims: Congenital tracheal stenosis (CTS) is a rare disorder almost always diagnosed in infancy due to respiratory failure. Often complicated with cardiopulmonary abnormalities, patients require early surgical intervention. It is extremely rare that patients survive undiagnosed. We experienced an adult case of CTS who was undiagnosed until intubation. Methods: Case report and literature review. Results: A 42-year-old female was admitted for right-sided spontaneous pneumothorax. She had a past medical history of right-sided spontaneous pneumothorax (three times in the past year), bronchial asthma, and atopic dermatitis. Recurrent right-sided pneumothorax indicated the possibility of catamenial pneumothorax. Thoracoscopy was planned for definitive diagnosis. On induction of general anesthesia, routine intubation was not possible due to tracheal stenosis. After various trials, intubation was finally successful with an uncuffed pediatric endotracheal tube (internal diameter 5.5 mm). There were no visible blebs or ectopic endometrium on the pleura. The surgery and postoperative course was uneventful. Chest Xray and computed tomography image showed bronchial stenosis (which was unnoticed prior to surgery). Postoperative bronchoscopy revealed tracheal stenosis due to complete tracheal rings. There were no findings suggestive of an underlying acquired disease; therefore we diagnosed her as CTS. Conclusions: We experienced a rare case of adult CTS. In English and Japanese literature, there has been only 10 reported cases of adult CTS. Four cases were diagnosed from imaging studies prior to intubation. Our case and 6 of the 10 reported cases were found only when routine intubation procedures were unsuccessful. Some cases required postponement of surgery. All cases required adjustment of intubation procedures or additional invasive methods. This highlights the importance of observing the bronchus carefully on imaging studies prior to intubation. Moreover, in patients with recurrent asthmatic episodes resistant to treatment, the possibility of CTS should be kept in mind. Silpakorn University, Faculty of Pharmacy, Nakhon Pathom, Thailand Background and Aims: The Leicester Cough Questionnaire (LCQ), a validated cough-specific QoL measure, is used to assess treatment efficacy for cough including physical, psychological, and social aspects. A Thai version of the LCQ (LCQ-T) has been recently validated. We aimed to investigate the MCIDs of the LCQ-T. Methods: Patients with > 3 weeks of cough were enrolled from the pulmonary and allergy clinics at Ramathibodi Hospital. They self-completed the LCQ-T and Borg Cough Scale at initial and repeated all questionnaires with the Global Rating of Change (GRC) scale at follow-up. The follow-up period was categorized, based on the previously reported responses to a given treatment for each specific disease, into 3 groups (<4 weeks, 4-16 weeks, and >16 weeks). For the anchor-based method, the MCID was defined as a change of the LCQ-T score that corresponded to the smallest improvement of GRC perceived by the patients (between +2 and +3). For the distribution-based method, the MCIDs were calculated from the standard error of measurement (SEM) and half of the standard deviation (SD). Results: A total of 107 patients with a mean (SD) age of 54 (15) years were included. The etiologies of cough were post-infectious coughand acute bronchitis (n = 37, 34.6%), asthma (n = 22, 20.6%), rhinosinusitis (n = 19, 17.7%), COPD (n = 10, 9.3%), and bronchiectasis (n = 19, 17.7%). The anchor-based MCIDs for the total, physical, social, and psychological domains were 1.1, 0.4, 0.4, and 0.4 respectively. The distribution-based MCIDs using SEM for the total and each domain were 0.8, 0.3, 0.3, and 0.3, and those using half of SD were 2.0, 0.6, 0.8, and 0.8 respectively. Conclusions: The clinically relevant change of LCQ-T scores (anchorbased MCIDs) was 1.1, 0.4, 0.4, and 0.4 for the total, physical, social, and psychological domains. Our MCIDs could be applied for sample size determination in future clinical trials. Background and Aims: Bronchiectasis is a complex chronic inflammatory airway disease with significant morbidity and mortality. Fatigue is a complex, disabling symptom which can be measured objectively. There are limited studies on fatigue in bronchiectasis. Its relationship between quality of life (QOL), anxiety, depression, lower limb muscle strength, exacerbation rate and airflow obstruction is unclear. We aimed to study the associations of fatigue, functional outcomes and airflow obstruction. Methods: We conducted an exploratory study on consecutive patients attending the bronchiectasis specialist clinic between April and September 2015. Demographics, sputum microbiology, body mass index (BMI), lung function tests, St George's Respiratory Questionnaire (SGRQ), 5 repetition sit-to-stand tests (5STS), modified Medical Research Council dyspnoea score (MMRC) and breathless-cough-sputum score (BCSS), hospital anxiety and depression score (HADS), sputum colour, hospital admission and emergency department (ED) attendance rate were analysed. Fatigue was measured by functional assessment of chronic illness therapy-fatigue (FACIT-F) score. Results: 25 patients (14 female) with a median (IQR) age of 69 (62.5-74.5) years were studied. Their median (IQR) percent predicted FEV ) and 17.4(16.05-22.2) respectively). None was current smoker. 17% of the patients had significant fatigue (FACIT-F <34), 8% had anxiety (HADS-A > 8) and 12% had depression (HADS-D > 8). Fatigue (FACIT-F) was significantly correlated with HADS (anxiety and depression) (r = −0.661, p = 0.001; r = −0.596, p = 0.003 respectively). 5STS was positively correlated with the number of ED attendances and hospital admissions (r = 0.604, p = 0.004; r = 0.734, p < 0.0001 respectively). No corrections in between fatigue, BMI, SGRQ, BCSS and predicted FEV 1 . Conclusions: Fatigue, anxiety and depression were common in patients with bronchiectasis. Fatigue (FACIT-F) was correlated with anxiety and depression (HADS). The lower limb strength (5STS) was positively correlated with rate of hospital admissions and ED attendances. 5STS, a potential novel predictor of exacerbation of bronchiectasis can be monitored as a treatment outcome. Background and Aims: Solitary pulmonary nodule is frequently encountered on chest x-ray and computerized tomography scan of chest. Differential diagnosis is board, ranging from benign granulomata to malignancy. Establishing the etiology of SPN in accurate manner assumes critical importance, since surgical resection in patient with earlystage lung cancer provides highest chance of cure. By the same token, avoiding thoracic surgery for benign SPN whenever possible does obviate significant morbidity. At present decision to serial CT chest or obtain tissue diagnosis depend on pretest probability of malignancy and characteristic findings from CT chest. Most informations obtained from foreign country, but we don't have actual data in Thailand where prevalence of tuberculosis is high. Objective: To study the associations between characteristic chest CT findings and pathological diagnosis in patients who had SPN in Phramongkutklao hospital. Methods: Retrospective study including patients who had SPN undergone chest CT and obtained pathological diagnosis in Phramongkutklao hospital. Results: Ninety-two patients, mean age 61.63 years were studied. Fiftyfour (58.7%) of them were male. Forty patients (43.48%) had history of smoking. Sixteen patients (17.39%) had previous malignancy. Mean diameter of SPN was 24.17 mm. They were located at upper lobes in 42 patients (45.65%), at lower lobes in 35 patients (38.04%). Pathological findings revealed malignant SPNs in 55 patients (59.78 %), granuloma in 20 patients (21.74%). Presence of smooth border was associated with benign SPNs (PR =0.27, P < 0.0001). Spiculated border was associated with increased prevalent rate of malignant SPNs (PR =1.89, P = 0.002). Satellite nodules were associated with benign SPNs (PR =0.3, P = 0.001). Pleural retraction was associated with increased prevalent rate of malignant SPNs (PR =1.5, P = 0.048). Conclusions: Spiculated border and pleural retraction from chest CT were associated with malignant SPNs whereas smooth border and satellite nodules were associated with benign SPNs. Background and Aims: Mesothelioma is the most common primary malignant tumor of pleura that arises from the mesothelial surfaces of pleura. The predominant cause is exposure to asbestos, with approximately 40%-80% patients having a documented asbestos exposure. Methods: A 60-year-old male farmer presented with right pleuritic chest pain, nonproductive cough, and low grade fever for 3 weeks. He also had dyspnea on exertion and weight loss 3 kg. Physical examination revealed T 38.2 C, RR 22/min. Respiratory system showed dullness on percussion and decrease breath sound at RLL. Chest radiograph demonstrated right pleural effusion.Chest CT showed a 1.7x1.3 cm enhancing soft tissue lesion at right hilar region, multifocal pleural thickening at anterior, lateral and posterior of right upper hemithorax, and moderate amount of right pleural effusion(figure 1). Pleural fluid anaylsis demonstrated yellow color, RBC 4240 cells/cumm 3 , WBC 280 cells/cumm 3 (mononuclear 84%, PMN 10% ), pleural fluid protein 5.51 g/dL (serum protein 6.44 g/dL), pleural fluid LDH 748 U/L(serum LDH 134 U/L). Pleural fluid ADA was 11 U/L. Pleural fluid acid fast stain was negative. Pleural fluid cytology was negative for malignancy. Results: Pathological findings of right pleural biopsy showed severe fibrosis with areas of hyalinization and diffuse infiltration by some solid sheets of small to large cells containing irregular nuclei with fine vesicular chromatin and prominent nucleoli. The immunohistochemical findings of the tumor cells were positive for CK5/6, Calretinin (figure 2), CK7 and EMA. The conclusion of the infiltrative tumor was malignant mesothelioma (epitheloid variant). Because of poor performance status, this patient received palliative treatment and insertion of ICD for release pleural fluid. The association between asbestos exposure and the development of malignant mesothelioma is well known. Nonetheless, a proportion of patients suffering from this disease do not appear to have documented exposure to asbestos fibers from any known source. Background and Aims: To apply Continuous Positive Airway Pressure (CPAP) can accelerate the absorption of pleural effusion due to several pathologic conditions. We assessed effect of CPAP on fluid absorption and talc pleurodesis outcome in order to control malignant pleural effusion. Methods: Case controlled study was designed comparing patients who underwent talc pleurodesis between January 2013 to December 2014. The primary end point of procedure duration, Chest Tube Drain (CTD) day, was compared between patients who were applied CPAP pressure 7-10 cmH2O, 6 hours per day before removing CTD after talc pleurodesis with the control group; conventional post procedure care. The secondary end point was pleurodesis successful rate. Results: Among 24 patients, twelve in each group, the procedure duration had trend to shorter in CPAP group (median,3.5 days; Q25-75, 3.0-5.0 days) than in the control group (median, 6.5 days; Q25-75, 3.5-9.5 days; OR, 0.95; 95%CI, 0.80-1.13; p = 0.11). CPAP group had trend to higher successful pleurodesis (75%) than in the control group (58.3%; OR, 2.14; 95%CI, 0.38-12.19; p = 0.39) Conclusions: CPAP applied after Talc Pleurodesis has trend of having shorter CTD duration and less failure comparing to the conventional care. CPAP application can be additional care in post pleurodesis patient. However, additional studies in large scale of patient are needed to confirm these findings. Background and Aims: Hypothyroidism as an etiology for bilateral pleural effusion is rare. The first case of pleural effusion associated with hypothyroidism was reported by Schneierson and Katz in 1958. They described a 73 year old male with myxedema and right sided pleural effusion that resolved following thyroid hormone replacement. This paper reports a case of a 58 year old Filipino female presenting with one week history of dyspnea. Methods: On examination, she has bradycardia (51 bpm), hypothermia (34.7 C), facial edema, decreased bibasal breath sounds and grade 2 bipedal edema. Initial chest radiograph revealed bilateral pleural effusion and chest ultrasound showed 670 ml at right and 412 ml at left. There was also massive pericardial effusion with tamponade. She underwent thoracentesis (right) and pericardiostomy which provided relief of dyspnea. Results: Different etiologies of bilateral pleural effusion including heart failure, liver cirrhosis, hypoalbuminemia, uremic pleuritis, connective tissue disease, pulmonary tuberculosis and malignancy were ruled out based on the available clinical data and laboratory examinations requested. Thyroid function tests revealed elevated TSH (>60 uIu/ml), decreased FT3 (<0.70 pmol/L) and decreased FT4 (<1.00 pmol/L). The patient was diagnosed with hypothyroidism (in myxedema crisis) and started on Levothyroxine 100mcg/tablet once a day. Patient remained hemodynamically stable and was eventually disharged improved. On follow up after two months, there was resolution of dyspnea and bipedal edema. Repeat chest x-ray revealed clear lung fields and repeat thyroid function tests also improved (less elevated TSH and normal FT3 and FT4 (7.11 uIu/ml, 7.3 pmol/L and 1.8 pmol/L, respectively). Conclusions: Hypothyroidism appears to be a rare cause of pleural effusions and is usually a diagnosis of exclusion. Therefore, as clinicians, a careful investigation of the clinical signs and symptoms along with judicious use of available laboratory test are of utmost importance to fully establish the diagnosis. Background and Aims: A 77-year-old woman presented with dypsnea, chest and back pain. She had been suffering progressive dyspnea for 22 years and receiving LTOT and bronchodilator therapy for COPD and respiratory failure. Methods: On physical examination she had bilateral fine crackles. She was admitted to intensive care unit and connected to NIV for respiratory failure. Results: She had anemia, elevated creatinine, potassium, and CRP levels. She also had P-ANCA positivity. Vasculitis was primarily considered in the differential diagnosis and systemic steroid was started at a dose of 80 mg/day (1 mg/kg/day). Her vital signs were improved, blood pH in arterial blood gas was normalized during follow-up and she was transferred to regular ward. However, she developed cardiorespiratory arrest on 20th day of admission; she was intubated and connected to mechanical ventilator. A thoracic CT demonstrated bilateral newly developed pleural effusions, predominantly peribronchovascularly and peripherally located areas of consolidation, and patchy ground glass opacities in lungs (Figure) . During follow-up, her general status suddenly deteriorated; she also developed anemia. With these signs and CT findings, alveolar hemorrhage was considered. She was administered pulse steroid (250 mg/day) therapy for alveolar hemorrhage secondary to microscopic polyangiitis (MPA). However, she died six hours after being connected to mechanical ventilator. Conclusions: MPA is a rare, ANCA-related small vessel vasculitis of unknown etiology. Its pathological hallmarks include alveolar hemorrhage due to fibrinoid necrosis and capillaritis in lungs, and focal segmentary necrotizing glomerulonephritis in kidneys. The prognosis of pulmonary hemorrhage is quite poor. Its treatment depends on its severity, and includes corticosteroids, cyclophosphamide, rituximab, mycophenolate mofetyl, and plasmapheresis. MPA shuld be considered and ANCA level be determined in cases with constitutional symptoms, dyspnea and accompanying chronic renal failure. Background and Aims: Choriocarcinoma is a rare malignancy of the trophoblastic cells which can metastasize to the lungs. This is a case of a 37 year old lady who was diagnosed with choriocarcinoma lung metastasis without progression to primary site tumour. Results: Patient was initially diagnosed as molar pregnancy in 2002 and has completed 3 cycles of Methotrexate and 7 cycles of EMACO. Her obstetric history revealed a miscarriage (2003) followed by 2 children delivered via C-section (2005 and 2009) . In 2011, she presented with dysfunctional uterine bleeding of which she was diagnosed as uterine fibroid and was treated with oral contraceptive pills. In March 2012, she then had amenorrhea and was suggested for myomectomy. However, she opted for conservative management and was started on dydrogesterone. In April 2012, she had a raised b-hcG (19,0021 IU) and subsequently did a total abdominal hysterectomy in May 2012 which confirms trophoblastic tumour. Subsequent follow up by transabdominal ultrasound noted no recurrence of disease with serial b-hCG persistently <2 IU. 2 years later, her b-hCG had increased to 12.1 IU and repeated transabdominal ultrasound showed a cystic lesion measuring 3x3 cm. However, she remains asymptomatic with static b-hCG levels and static size of the cystic lesion on serial ultrasound. Unfortunately, from August 2015 her b-hCG levels started to increase in trend. A Contrasted CT TAP done showed a large left lung lesion at left lower lobe (7.7x9.7x8.3 cm) and histopathology from the CT guided lung biopsy confirmed it as metastatic trophoblastic choriocarcinoma. She was then subsequently referred to oncology for further management. Conclusions: This case highlight that lung metastasis can occur without local recurrences in choriocarcinoma and should be suspected early if the b-hCG is increasing in trend. Background and Aims: The abnormal findings of chest images in patients with early stage allergic bronchopulmonary aspergillosis (ABPA) are non-specific and diagnosis is often difficult. Although there are some articles showing the changes of abnormal findings on chest x-ray in ABPA patients over time, no paper has described a long-term follow-up with chest CT images. Here, we report a case of a 66 year-old male with ABPA having past history of bronchial asthma and upper pharyngeal cancer, in which annual changes were observed by chest CT for 5 years. Methods: Chest CT was performed annually as a follow-up abnormal finding. The diagnosis of ABPA was made using the Greenberger and Patterson diagnostic criteria. Results: Initial chest CT, following radiation therapy and radical lymph node dissection against pharyngeal cancer, revealed mucoid impaction and bronchial wall thickenings. Within 5 year follow-up, abnormal findings were repeatedly withdrawn and exacerbated. After diagnosis of ABPA was made, lung abnormalities were improved through initiation of corticosteroid and antifungal medication. Conclusions: This patient was misdiagnosed with bronchopneumonia for 4 years, following the initial CT in 2010. We present this case and the resulting findings as an illustrative reminder to consider ABPA in patients with bronchial asthma and non-specific CT findings. Background and Aims: Inflammation of one or more serous membranes resulting in pleural, peritoneal, or pericardial effusion is common in patient with SLE. However, cases of chylous ascites and chylothorax are extremely rarely. Herein, we report a case of chylothorax in a SLE patient. Case presentation: A 31 year-old Malay lady with parity 2 with chief complaints of fever associated with cough, shortness of breath associated with pleuritic chest pain, progressive oedema and abdominal distension for the past 1 year and was managed in our centre. Medical history revealed that the patient was diagnosed with SLE with bilateral pleural effusion in 2008 and was under follow up for persistent pleural effusion. Physical examinations revealed tachypnea with reduce breath sound in lungs, crepitations of lower zone, stony dullness on percussion and reduced vocal resonance. Laboratory tests showed high TWC indicating infection. CT thorax revealed worsening serositis with massive pleural effusion. Chest tube insertion revealed chylothorax. Pleuroscopy revealed adhesion, chalky white effusion and hyperaemic pleural with whitish patches. Bilateral chest drainage revealed exudative effusion of 3.8 liter. Pleural fluid analysis revealed 67100 mg/L of protein, triglyceride of 2.9 mmol/L(>110 mg/dl). The patient required prolonged chest drainage more than 2/52 but she was not suitable candidate for surgery in view of the high risk of bleeding. She was restarted on high dose of prednisolone 40 mg OD, HCQ 200 mg OD and azathioprine 50 mg OD. Three months after tapering dose of prednisolone, her effusion was reduced base on CXR and she was clinically remained asymptomatic. Discussion and Conclusions: Chylous ascites and chylothorax have rarely been described in patients with SLE. Therefore, besides analysis of the blood samples, detailed analysis of effusions of the serous membranes should be carried out. Background and Aims: Negative pressure pulmonary edema (NPPE) secondary to post upper airway obstruction is well-described phenomenon but incidence is very rare. It is important different diagnosis and fast intervention to NPPE. We experienced the NPPE after post extubation during emergence from general anesthesia and want to share our experience how it happen and goes. A 38-year-old healthy man underwent an endoscopic pansinus procedure. Following administration of 30 mg lidocaine, 50mcg fentanyl, 120 mg propofol, and 50 mg rocuronium, he was easily intubated with a 7.5-mm oral endotracheal tube. Anesthesia was maintained using sevoflurane and rocuronium followed by fentanyl for analgesia. The patient underwent an uneventful surgery lasting about 3 hours. During anesthesia emergence, there was lots of bleeding in patient's nose and oral cavity. He was very agitated and coughed several times. After given information about place and situation, the patient calm down and breathe spontaneously. After extubation, he had adequate breathing and pulse-oximetry (SpO2) showed around 96%, transferred to post anesthesia care unit (PACU). Immediate arrived PACU, SpO2 89% was checked, oxygen 10 L/min supplied via non breathing facial mask. It rose to 95% and last 10 minutes, but decreased to 80s% again. The patient denied dyspnea at all, but started to sweat. Even though administration of sugammadex 100 mg, and lasix 5 mg because of pulmonary edema showed on postop chest x-ray. Hypoxemia aggravated -SpO2 decreased to 83% and PaO2 chekced 54 mmHg under 100% O2 supply with manual ventilation assist. After administration midazolam 5 mg and cisatracurium 12 mg, he was reintubated easily, transferred surgical intensive care unit and mechanical ventilation was begun. Approximately 2 day later, pulmonary edema had completely resolved, both radiographically and clinically. The patient was weaned off the ventilator and extubated 2 days after operation day. He was transferred to general ward, observed 2 more nights, and discharged home without any complication. Methods: Amyloidosis is a rare disease, which caused by deposition of abnormal protein, called amyloid fibrils and caused disruption of normal tissue. Amyloid fibrils can confine deposit in only one organ or many organs, caused localized amyloidosis or systemic amyloidosis. However, respiratory involvement in amyloidosis is rarely seen. We, here, reported a case of tracheobronchial amyloidosis. Results: A 46-year-old Thai man presented with left eyelid mass for 1 year, which ophthalmologist decided to remove the mass. Preoperative investigations were all within normal limit. During intubation and intraoperative period were uneventful. After finished the surgery and extubation period, anesthesiologist found that there was 200 ml of bright red blood came from endotracheal tube. Massive hemoptysis was continued during he was admitted in ICU. He had no prior history of respiratory tract disease except occasionally scanty hemoptysis, which he had never mentioned before. The CBC, coagulogram, blood chemistry and urine analysis were all normal and there was no sign of systemic bleeding. Chest X-ray and CT scan showed multifocal consolidation and ground glass opacities scattering in both lungs with circumferential wall thickening along trachea and right/left main bronchi with some calcified bronchial wall. (Figure1) He underwent bronchoscopy, beside tracheobronchomalacia, we found irregularity of airway mucosa extended from subglottic area to second generation of bronchus with contact bleeding from lesion. We tried to stop bleeding but failed. Massive hemoptysis was continued, which he needed blood transfusion everyday. The patient was suffered from ventilator-associated pneumonia and was dead later. The pathological reports of tracheal tissue and eyelid mass were consistent with amyloidosis. (Figure2) Conclusion: This case represents a rare clinical manifestation of tracheobronchial amyloidosis. The cause of bleeding in this patient due to fragility of blood vessels infiltrated with amyloid proteins and disabling its normal vasoconstriction properties. Background and Aims: Sclerosing pneumocytoma (SP) is a rare primary pulmonary tumor, which was first described by Liebow and Hubbel in 1956. Generally classified as benign, however it occasionally metastasizes to other organs. Surgical resection is curative treatment. Here we report a case of SP presenting with a slow growing lung mass. Methods: Case presentationIn June 2006, an asymptomatic 47-year-old female hotel-housekeeper visited our hospital for evaluation of a slow growing lung mass detected on follow-up chest X-rays. The homogeneous mass with well-defined border was first observed on an annually screening chest X-ray in 2000. Computerized tomography of chest revealed a 4x3 cm heterogeneously enhancing mass without calcification in the lateral basal segment of the left lower lobe (Fig1). The patient was initially diagnosed with possible early stage of lung cancer or a growing tumor. Thus, she was referred to a cardiothoracic clinic for surgical evaluation and then underwent lobectomy of the left lower lung. Gross pathological examination revealed a 4x3x2.5 cm well circumscribed gray-white mass. Microscopic examination showed the mass was composed of numerous spaces lined by endothelial and ciliated columnar cells with papillary arrangement. The remaining stroma showed hypercellular alternating with sclerotic, hyalinizing and edematous area, and the stromal cells possessed rather monotonous round basophilic nuclei with inconspicuous nucleoli. Mitotic figures were rarely seen. The findings were compatible with benign sclerosing pneumocytoma. The patient was scheduled for annual follow-ups. During a 10 year follow-up period, there was no evidence of tumor recurrence. Discussion: We demonstrated the patient with primary pulmonary SP. This rare tumor occurs predominantly in middle-age women. Majority of cases present as asymptomatic abnormalities in thoracic images without pathognomonic radiographic findings, leading to the difficulty in making the correct preoperative diagnosis. An asymptomatic 19 year-old man presented for evaluation of a mediastinal mass. On chest computed tomography scan, the mass demonstrated contrast enhancement and multiple scattered calcifications. T1-weighted MR imaging revealed a heterogenous mass of low to intermediate signal intensity, and T2-weighted MR imaging revealed a hyperintense mass lesion with a flow void that represented an enlarged vein draining into both of the superior and inferior vena cava (SVC and IVC). Contrastenhanced MR imaging revealed that the mass was multilocular and marginally enhanced. From these imaging findings, the mass was diagnosed as mediastinal LVM. His LVM was too large to be removed. Moreover, because his LVM had abundant blood flow and also direct connections to SVC and IVC, surgery and sclerotherapy were thought to have high risk of complications such as bleeding and systemic infarction. Therefore, we decided to follow-up the patient without any treatment. The mass remained stable on CT images obtained six months after. Discussion: Vascular malformation of the mediastinum is rare and accounts for 0.5% of mediastinal tumors. Until today, 14 cases of mediastinal LVM have been reported. Biopsy is needed for the definitive diagnosis, however, it could confer risks of bleeding. Treatment choices of vascular malformations are surgery and sclerotherapy, and most of those patients were treated with surgery. In our patient, LVM was too large to be removed completely. Conclusions: In conclusion, we presented a case of huge LVM of the mediastinum diagnosed with imaging findings. This condition is very rare and biopsy is sometimes difficult, therefore, the characteristic imaging findings are important for definitive diagnosis. Background and Aims: Introduction Spontaneous pneumothorax (SP) can be primary (PSP) or secondary (SSP) based on the absence or presence of an underlying lung disease respectively.It is associated with high recurrence rate,if untreated.Herein,we present a unique case of a 21-year old male with right upper lobe mass who presented with recurrent spontaneous pneumothorax. Case presentation A 21-year-old male,non-asthmatic,non-smoker. 2 years PTA,he had sudden chest pain.No other symptoms.Pneumothorax, left was seen on chest X-ray.Tube thoracostomy,left was done.Chest CT scan was unremarkable.He was discharged.1 year PTA, he had sudden right-sided chest pain. Chest X-ray showed pneumothorax, right.High-flow O2 therapy was given.Chest CT scan was unremarkable.Pneumothorax resolved.Discharged improved.3 weeks PTA, he had sudden right-sided chest pain with dyspnea.No other symptoms.Pneumothorax, right was noted on Chest X-ray.Tube thoracostomy,right was done.Chest CT scan: biapical blebs;hazy confluent density,RUL; bronchiectasis,right posterior basal segment.Anti-TB therapy was started.He was referred to our institution.He has BMI of 17.2 kg/m 2 .Preoperative pulmonary evaluation was done.Due to failed VATS, he had open thoracotomy,right.Blebectomy andvwedge resection of the pulmonary mass was done with mechanical pleurodesis. Biopsy of the mass was a tuberculoma.Postoperative period was unremarkable. He was discharged after 10 days.Anti-TB therapy was completed Discussion: PSP develops among those without underlying lung disease.It is more common among young, tall, thin males like our patient. SSP is more serious than PSP and have existing pulmonary conditions. Our patient had both types of spontaneous pneumothorax (recurrent). Exact pathogenesis of PSP remains unknown but may be due to spontaneous rupture of subpleural bleb or bullae. Management may be surgical or nonsurgical depending on the size of the pneumothorax, symptomatology and recurrence. In retrospect,surgical intervention was already indicated in our patient.However, VATS is not readily available in our country Conclusions: Exact pathogenesis of PSP is still unknown. Close followup after each episode of SP is needed. Spontaneous pneumothorax should be addressed with advanced surgical intervention when indicated Background and Aims: Exudative pleural effusions can be determined using the Light's criteria.The most common causes of exudative pleural effusions are pneumonia, tuberculosis and malignancy.This study was done to determine the use of serum and pleural protein (Pr) to lactate dehydrogenase (LDH) ratio in the diagnosis of effusions secondary to these disease entities.The pilot study was made by Talasaz, et al.It showed significant differences in mean serum and pleural Pr/LDH among the parapneumonic,malignancy and tuberculosis group. Methods: A total of 103 adult patients were included in the study who were admitted or seen in the Philippine Heart Center from January 2014 to June 2015. These patients were diagnosed with exudative pleural effusion wherein causes of which were established based on clinical data and pleural fluid analysis and/or biopsy when needed. They were subsequently grouped into parapneumonic, tuberculous and malignant pleural effusions. The data were summarized as means and standard deviation for numeric variables and frequencies and percentages for categoric variables. Homogeneity of characteristics between the three groups were tested using the Analysis of Variance (ANOVA) for quantitative variables or Fisher's exact test for qualitative variables. Comparison between the mean serum and pleural fluid Pr/LDH ratio between the three groups (i.e. malignancy, TB and parapneumonic) were determined and tested using the ANOVA. Tukey HSD Test was done for each significant ANOVA result. The level of significance (alpha) was set at 0.05. The presence of cancer and coronary artery disease play a role in the development of an exudative pleural effusions with p-value of 0.000 and 0.007 respectively. Accordingly, there was no significant difference in the serum and pleural LDH and serum and pleural protein between groups as well as their serum and pleural Pr/LDH ratios Conclusions: Serum and pleural Pr/LDH ratio is unable to further differentiate the underlying cause of an exudative pleural effusion. - (Table 01) .PF adenosine deaminase (ADA) cut off of 40 IU/L had a good sensitivity (88%), specificity (80%), positive and negative predictive values (PPV 83%, NPV 86%) with a good overall validity of 84% for TPE. Cut off of 60 IU/L showed a better specificity (93%) and virtually excluded chronic PPPE, but with low sensitivity (55%) and NPV (65%).PF lymphocytosis was sensitive (97%) for detecting TBE, but with low specificity (44%). Neutrophil predominance, which was present among 44% of PPPE, had a NPV of 93% for TBE.Both TBE and PPPE had mean PF sugar below 60 mg/dl, however this finding was neither sensitve (52%) nor specific (60%). Conclusions: In our study obstructive sleep apnoea is common among males. male to female ratio is 3.7:1. male to female ratio increase with increasing severity. Osa is more common in 31-60 age group. associated co morbidity like diabetes and hypertension were common among osa patients. Increasing bmi, mallampati score, neck circumference go together with increasing severity of osa. Therefore the demographic patterns of osa during last two years in central sri lanka is similar to the established demographic descriptions the world over. Background and Aims: Spirometry is performed in pulmonary laboratories and physician offices. Published reports of quality of spirograms and of spirometric interpretations is low. Flow-Volume loops, by themselves are inadequate for evaluation; they do not assure adequate test quality. The forced expiratory maneuver involves 3 variables: Flow, Volume, and Time. By rotating the 3 axes one obtains Flow-Volume and Volume-Time curves. Spirometry devices do not commonly recognize short exhalation times. They usually identify the end of exhalation when inspiration begins, regardless of breathholding. Short expiration times truncate the forced expiration and produce high FEV1/FVC ratios. The FEV1/FVC approaches 1.0 as the forced expiratory time approaches 1 second. Therefore short forced expiratory times can mask airway obstruction. The information in the Volume-Time curve and in the Flow-Volume curve are complementary. We aim to illustrate the inadequacies of Flow-Volume curves when used in isolation for PFT interpretation. Methods: We used clinical spirograms from pulmonary function laboratories at Intermountain Healthcare, Inc. Results: Breath holding during the forced expiration is obvious in the Volume-Time curve but difficult to identify in the Flow-Volume curve (red arrows in Figure 1 ). Normal spirograms (Figure 2A) can be mimicked by short exhaltion times ( Figure 2B ). This is only apparent if the Volume-Time curve is examined as well ( Figure 2C ) and the breath holding and short exhalation times are recognized. The dashed red line in Figure 2C indicates 1 second, when breath holding becomes clear. The exhalation time in Figure 2D will be reported by the spriometry device as about 8.7 seconds (the right red arrowhead and dashed vertical line) whereas the true exhalation time is only 1.4 second (the left arrowhead and dashed vertical line). Conclusions: Spirometry interpretations should include examination of both Flow-Volume and Volume-Time curves. Quality assurance cannot be achieved with Flow-Volume curves alone. University of Utah, Internal Medicine Pulmonary/Critical Care Division, Salt Lake City, USA, and 2 Gleneagles Hospital, Asian American Liver Centre, Singapore, Singapore Background and Aims: The current approach to clinical decision-making is based on individual experts considering large amounts of information. These individual experts make variable decisions when faced with the same information. Much of this variation is unwarranted and not linked to good evidence. Medical care quality is reduced by unwarranted variation in clinical decisions, both between institutions and between physicians. Major reductions in unwarranted variation generally require effective physician decision-support. However, this decision-support should provide personalized instructions matched to individual patient needsa goal not met by almost all current guidelines and protocols. We used a replicable clinician decision method that produces consistent context-sensitive personalized patient care instructions from detailed computer protocols. Protocol rules applied prospectively, at the time of clinician decision-making, produce a replicable decision (same decision from different clinicians) (- Figure 1 ). Protocol rules derived retrospectively from database analysis do not. We aim to describe the differences between our method and guideline or protocol rules generated from retrospective data analysis. Methods: We developed and implemented clinically detailed computer protocols for management of mechanical ventilation, IV fluids, blood glucose management and for pulmonary function interpretation, during the past 30 years. We exported protocols across cultures, including Singapore, and across medical disciplines, with clinician compliance of 95% with the protocol instructions. Results: Common paper-based protocols are so variable that comparison of the study results becomes difficult and lead to conflicting results. Figure 2 illustrates variability in insulin dosing recommendations for 12 published protocols (gray area): IV insulin infusion rates (insulin units / hour); Van den Berghe protocol (dashed line); eProtocol-insulin, one of the detailed, context-sensitive, computer protocols developed at Intermountain's LDS Hospital. Conclusions: Detailed computer protocol use is feasible in USA and Singapore. Implementations of detailed computer protocols in the Asian Pacific region can increase quality of care and the scientific credibility of clinical research. University of Utah, Internal Medicine Pulmonary/Critical Care Division, Salt Lake City, USA, and 2 Gleneagles Hospital, Asian American Liver Centre as Department, Singapore, Singapore Background and Aims: The Hippocratic (expert, authoritarian) model of clinician decision-making requires clinicians to manage complex information and use judgment to make the "best decision." Medical decisionmakers intend to consistently improve clinical outcomes for individual patients. This goal requires decisions to be tightly linked to best evidence. However, it has been known for decades that clinicians do not consistently make decisions, or carry out actions, linked to best evidence. One of the contributors to the failure of clinicians to make consistent decisions linked to best evidence is limited human cognition due to the limits of short-term (working) memory. Psychologists have known for decades that short-term memory is limitedestimated current limit = 4 AE 1 constructs before decisions become degraded. We aimed to identify an important barrier to clinical use of decision-support with detailed computer protocols. Methods: We used detailed computer protocols based on best evidence to standardize clinician decision-making. We identified a 12-step method for protocol development. Multiple clinicians following the protocol instructions make the same decision when faced with the same patient data. The protocols respond to changing patient context and generate personalized medicine instructions matched to the needs of the individual patient. Results: Collaborating physicians followed the personalized medicine protocol instructions 95% of the time, and eliminated differences between institutions, including the National University Hospital of Singapore (- Figure 1a , b) ( Figure 2 for partial glucose protocol screen image). We used detailed computer protocols for decades, but some clinicians resist adopting protocols. We realized the first step for such protocol use is the recognition that clinicians, like all humans, overestimate their abilities (according to the illusory superiority principle). Conclusions: Detailed computer protocol use is feasible and used in Singapore. Once clinician limitations are recognized, systematic implementation of detailed computer protocols should allow the uniform delivery of good medical care in developed and developing countries. Teaching Hospital, Respiratory, Kandy, Sri Lanka, and 2 Teaching Hospital, Respiratory Medicine, Kandy, Sri Lanka Background and Aims: The diaphragm is an important muscle in ventilator function. Evaluation of diaphragmatic function on undiagnosed breathlessness is important. Diaphragmatic weakness is commonly suspected by identifying the elevated hemi-diaphragm on chest radiograph. The aim of this study was to describe the demographics, and etiology of patient with diaphragmatic weakness in the absence of other obvious causative abnormalities on chest x-ray. Methods: Data was collected from patients with elevated hemi-diaphragm on chest radiography from april 2014 to june 2016. A questionnaire based interview was used to to identify symptomatology and to collect demographic data. All the patients were clinically assessed and relevant investigations were carried out as.cxr, pulmonary function test, fluoroscope, ct chest, nerve conduction study of phrenic nerve, emg of diaphragm, cervical spine x-ray and other general relevant investigations. Results were analyzed using microsoft office excel. Results: 28 Patients (78.5% male) with a mean age of 59.5 (range 44 -75) were selected. Fluoroscopy revealed 9 (32.14%) of non functioning. 19 had normal (67.8%). Out of 28 patients, 18 had restrictive pattern, 9 normal and 1 obstructive pattern. Only 9 patients had moderate impairment of mvv. In patient with udp nerve conduction revealed phrenic nerve palsy (pnp) in 6 (66.6%). There was no evidence of myopathy in diaphragmatic emg in these patients. Phrenic nerve conduction was normal in 3 and 2 of them had eventration of diaphragm. Out of 6 patients with pnp, 1 had a past tb fibrosis with bronchiectasis, 2 had a dm and no causes were identified rest of the 3 patients. Conclusions: This case series revealed one third of apparent elevation were due to diaphragmatic weakness. Out of which, majority (66.6%) of patients with udp had pnp. 2 of them had diabetes mellitus and 1 had a past tb fibrosis. In 50% of cases could not identify any obvious pathology. The patient was a 48-year-old woman who had suffered from refractory pneumothoraces of both lungs since she was 27 years old. At the age of 29, she underwent pleurodesis of the left chest cavity, resulting in no recurrence of pneumothorax on the left side. Her family history included pneumothoraces in her brothers, her maternal aunt, and her cousin. The patient had a unique distribution of multiple lung cysts located in the lower-medial zone of the lung field adjacent to the interlobar fissure and abutting the peripheral pulmonary vessels; these findings led to a strong suspicion of secondary pneumothorax caused by Birt-Hogg-Dubé syndrome (BHDS). She was genetically diagnosed with BHDS by means of a peripheral blood test and underwent surgical reinforcement of the whole visceral pleura of the right lung with absorbable cellulose mesh (Surgicel ® , Ethicon) to prevent a recurrent pneumothorax. Unpredictably, thoracic endometriosis was detected on the central tendon of the right diaphragm. The endometriosis was resected with a stapling device, followed by the surgical reinforcement of the diaphragm using Surgicel ® . The postoperative course was uneventful, and no recurrence of pneumothorax was recorded during follow-up for 4.5 years after the surgery. Teaching Hospital, Respiratory, Kandy, Sri Lanka, and 2 Teaching Hospital, Respiratory Unit 2, Kandy, Sri Lanka Tuberculosis is the second leading infectious cause of death world wild, killing about 2 million people per year, despite a potentially curable disease. Sri lanka is considered as a country with moderate risk of tuberculosis. There for it is essential that knowledge of healthcare professional regarding tuberculosis and its management needs to be up to date in order to improve the management Objective: To find the awareness of tuberculosis and its management among nursing stuff attached to T.H. Kandy Methods: The study was done at teaching hospital kandy during routine health education program. Two questionnaires consist of 25 stems covering etiology, symptoms and signs diagnosis treatment and drug side effects drug storage, dots spread of the disease, tuberculosispregnancy and lactation were given, each to be completed before and after the program.results were analyzed using microsoft xl 2010. Results: Total number of respondents was 80. out of them 75% were female. Total marks obtained by 80 respondents for pre and post program in 8 identified areas of questioners were calculated. The average marks obtained for pre evaluation questioner was 80.8% and post evaluation questioner was 93%. The knowledge regarding monitoring patients during treatment and tuberculosis in pregnancy and lactation was poor in pre evaluation and showed satisfactory improvement in post evaluation. S. PUENGPAPAT faculty of medicine thammasat university, medicines, Pathumthani, Thailand Background and Aims: We define these undiagnosed pleural effusions as those that remain undiagnosed after initial thoracocentesis and repeat thoracocentesis with pleural biopsy. The most common causes are malignancy and tuberculosis, but acute pulmonary embolism (APE), pneumonia and many other causes should be considered as a potential cause. Methods: A-78-year-old Thai male physically active presented with dry cough and dyspnea on exertion for 6 months. He had insignificant weight loss. His physical examination were as follows; BP 96/68 mmHg, heart rate 92 /min, oxygen saturation 98% room air, no pitting edema of legs. His chest x-ray revealed pleural effusion at right lower lung field (figure 1). Right thoracocentesis was done 2 weeks after presentation. Serosanguinous pleural fluid with RBC 280,000 cells/mm 3 , WBC 622 cells/mm 3 , monocyte predominate, protein 4.2 g/dl was observed. In the next month, his clinical and chest x-ray were the same. The second right thoracocentesis was done. It was serosanguinous fluid again. Pleural fluid for ADA was 17 U/L. Therefore, CT chest was done. Moderate amount of right pleural effusion with passive atelectasis of right lung was observed. No lymphadenopathy was detected. Consequently, the third right thoracocentesis with pleural biopsy was done. It was negative cytology for malignancy. Pathology was no granuloma, or malignancy. Finally, CTPA was done. A small intraluminal filling defect in segmental branch of pulmonary artery which supply anterior segment of right upper lung was seen (figure2). Figure 1 : chest x-ray (PA,upright) shows right pleural effusion We report a case of IgG4 related pulmonary disease in male, 71-yearsold presented with progressive dyspnea and significant weight loss for 3 months. Physical examination revealed only mild pale conjunctiva with small submental mass. Laboratory study showed mild anemia, mild renal impairment, and increased serum globulin level. Serum protein electrophoresis showed polyclonal gammopathy with negative result of immunofixation test. Bone marrow pathology and immunohistochemistry showed lymphoplasmacytic infiltration with normal plasma cell. Submental mass was dissected and also revealed lymphoplasmacytic infiltration. Chest radiography and chest computed tomography showed mediastinal adenopathies with bilateral multifocal patchy opacities and thickening interlobular septa (figure 1). Bronchoscopy with transbronchial biopsy was performed. Lung parenchymal pathology also revealed lymphoplasmacytic infiltration with positive tests for CD38 and IgG4 with IgG4:IgG positive cell ratio of greater than 40%. Serum IgG subclass also showed IgG4 level over 7,230 mg/dL. A diagnosis of IgG4 related pulmonary disease was made and the patient was subsequently treated with prednisolone. After approximately one month of treatment with prednisolone, his dyspnea was markedly improved. Background and Aims: Co-infection between higher bacteria and endemic fungi is quite rare in normal persons. Here is the report the rare case of lung abscess caused by Actinomyces and Histoplasma in an immunocompetent patient. Methods: A 48-year-old man was referred for the evaluation of progressive pulmonary lesion. He had no prior medical history until the presence of cough and left-sided pleuritic chest pain last year. CXR at that time showed 3.5 cm mass-liked lesion at left lower lobe and the bronchoalveolar lavage fluid revealed positive AFB and Mycobacterial tuberculosis from the cultures. Serology for HIV was negative. After complete treatment with standard anti-TB drugs for 6 months, his symptoms were not improved and CXR showed enlargement of an initial lesion with crescent formation. Results: At Siriraj Hospital, physical examination was remarkable only digital clubbing. Chest CT scan demonstrated a 4.4x3.3x3.7 cm cavity at lateral basal segment of left lower lobe with surrounding centrilobular nodules. Repeat bronchoscopy was performed and foul smell discharge with necrotic tissue was found at lateral basal segmental bronchus. Histopathology showed squamous cell metaplasia and marked chronic inflammation with granulation tissue. Thoracotomy with segmentectomy was performed, pathological examination demonstrated thin filament grampositive branching filamentous bacteria bordered by eosinophilic projections of Splendore-Hoeppli material, consistent with Actinomyces spp. A small necrotizing granulomatous nodule containing budding yeast was also found, morphologically favor Histoplasmosis spp. His symptoms and CXR were gradually improved after treatment with co-amoxyclav and itraconazole. However, subsequent bacterial and fungal cultures were negative. Conclusions: Actinomycosis and histoplasmosis are now uncommon lower respiratory tract infections. It can manifest as localized consolidation, lung nodule, mass, or even a cavitary lesion as in this case report. But the superimposed infection with these 2 agents in the pre-existing destroyed lung lesion from pulmonary TB has not been reported. All patients presented with non-life-threatening hemoptysis with the duration of 1 week to 2 years, three of them also had pleuritic chest pain and two of them complained of decreased appetite and weight loss. Initial diagnosis of pulmonary tuberculosis with negative sputum smears were impressed in all patients. However, subsequent history of ingesting raw crab and crayfish nearby the waterfall were established. Two of three patients who had CBC results revealed eosinophilia (absolute eosinophil count 762 /mm 3 Conclusions: Pulmonary paragonimiasis may mimic of pulmonary tuberculosis or others acute and chronic lung diseases. Thorough history taking and identifying their eggs in clinical specimens can ravel the definite diagnosis. EBV-associated smooth muscle cell tumor is a rare subset of smooth muscle tumors that occurred in immunosuppressed individuals. Herein we report a 29 year-old male, living with HIV infection, had been taking antiretroviral agents (zidovudine, lamivudine and lopinavir/ritronavir) for 2 years, with recent CD4 was 327 cell/mm3 (16.6%). He presented with chronic cough and significant weight loss for 3 months. The physical examination showed resonance on percussion and decreased breath sound over left lower lobe area. Chest x-ray demonstrated atelectasis of the left lower lobe consistent with computed tomography (CT) of the chest revealed a collapse of left lower lobe attributable to an endobronchial mass at the left main bronchus. The CBC and blood chemistry were normal. Fiber-optic bronchoscope was performed and discovered the endobronchial mass at the left main bronchus causing nearly complete obstruction. The lesional biopsy was done. The pathology showed a smooth muscle cell tumor and the immunohistochemistry strains were positive for desmin, smooth muscle actin, and muscle actin, whereas, were negative for S100, ALK and CD68. The request for EBV in situ hybridization demonstrated positivity. He was subsequently scheduled for rigid bronchoscopy with Argon coagulation of the tumor with removal, unevenfully. He was advised to continue antiretroviral therapy and close follow-up without locoregional recurrence until now. In conclusion, we reported a rare case of HIV-related EBV-associated endobronchial smooth muscle cell tumor and successful treatment with tumor resection and antiretroviral therapy. Background and Aims: In order to observe the effect of tanreqing combined with antibiotic treatment of pneumonia in children. Methods: 100 children pneumonia patients were randomly divided into treatment group and control group. Tanreqing was given in the treatment group combined with antibiotic therapy, and antibiotics were only given in the patients of the control group. Results: The recovery time of body temperature in treatment group was shorter and the time of cough was significantly shorter than the control group. There is a significant difference in the average length of hospitalization time(P < 0.05)The effect of the treatment group was better than the control group. Background and Aims: Positioning of a lightwand in the midline of the oral cavity is quite challenging in patients with cervical immobilization. Direct laryngoscopy allows the lightwand tip to easily access the glottic opening. We tested our hypothesis that laryngoscope-assisted lightwand intubation allows more successful endotracheal intubation than does conventional lightwand intubation. Methods: 162 patients requiring cervical immobilization during intubation for cervical spine surgery were randomly allocated to two groups. The conventional lightwand technique was used for endotracheal intubation in the control group (group C, n = 80), whereas the laryngoscope-assisted lightwand intubation technique for the laryngoscope-assisted group (group L, n = 82). In the group L, a Macintosh laryngoscope was inserted into the oral cavity and advanced past the tongue until the epiglottis tip was visible. The lightwand tip was placed below the epiglottis under direct view of the epiglottis tip. The success rate of intubation on the first attempt, intubation time, hemodynamic changes, and postoperative airway complications were evaluated. Results: The success rate of intubation on the first attempt was significantly higher (89.0% vs. 75.0%, P = 0.034) and the number of scooping movements was significantly lower [median (IQR), 2 (1-3) vs. 0 (0-1), P < 0.001] in group L than group C. Intubation time, postoperative sore throat score, and incidences of hypertension and tachycardia, postoperative oral mucosal bleeding, and hoarseness were comparable between two groups. Conclusions: laryngoscope-assisted lightwand intubation allows more successful intubation on the first attempt without increasing intubation time compared with traditional lightwand intubation in patients requiring cervical immobilization during intubation for cervical spine surgery. Background and Aims: The pneumonia is main cause of death among the patients with pneumoconiosis. Howevere, there is few studies concerning on the associated factors with pneumoconiosis and pneumonia. Therefore, the aim of this study was to evaluate factors associated with increased risk of mortality from pneumonia among patients with pneumoconiosis. Methods: Medical records of 103 pneumoconiosis patients hospitalized for pneumonia were investigated. After excluding specific conditions (lung cancer or other malignancy,insufficient medical records, female patients) were excluded. Final eligible population was 82. The subjects were divided into two groups byclinical outcome of pneumonia, the deceased group and the survival group. The two groups were compared interms of age, smoking history, episode of recent pneumonia, concomitancy of interstitial fibrosis or fungal ballinfection, extent of small opacities, grade of large opacities and results of spirometry. Multiple logistic regressionwas applied to determine the association between these variables and mortality from pneumonia. The deceased group showed more frequent history of recent pneumonia (p = 0.006), higher prevalence ofinterstitial fibrosis (p = 0.007) and longer hospitalization period (p = 0.044). The proportion of subjects who haddecreased FVC, less than 70 % of predicted value, was higher in the deceased group (p < 0.001). In multiple logisticregression, after adjusting age, smoking history, recent pneumonia, fungal ball, large opacity, profusion and FVC (orFEV1) less than 70 % of predicted value, history of recent pneumonia, concomitancy of interstitial fibrosis, type ofpneumoconiosis and fungal ball presented statistically significant association with mortality from pneumonia. Conclusions: The concomitancy of fungal ball or interstitial fibrosis, history of recent pneumonia within last90 days, type of pneumoconiosis, FVC less than 70 % of predicted value, FEV1 less than 70 % of predicted valuepresented statistically significant association with mortality from pneumonia. More attention should be given topatients who have such factors when treating pneumonia with pneumoconiosis. Background and Aims: Post-operative pulmonary complications are common among patients undergoing major surgery. Perpetual Succour Hospital is one of the major tertiary hospitals in Cebu City, Philippines. Since no data is available, the authors have therefore have decided to determine the incidence and outcomes of Post-operative complications in these patients Methods: This paper is an observational-analytical prospective study on 130 patients who underwent major surgery at Perpetual Succour Hospital. Patients were checked prior to operation and followed-up post-op to note development of post-operative pulmonary complications, identifying risk factors and types of complications developed as well as their subsequent outcomes. Results: The overall incidence of is low at 3.9% in the studied patients undergoing major surgery at Perpetual Succour Hospital. Among the complications pneumonia, atelectasis and pleural effusion were documented. These were seen to arise at 48-72 hours post-operatively. Background and Aims: The efficiency of professional activity of primary care physician can depend on a number of factors that determine conditions of the work, mechanisms and the degree of the achievement of aims. The aim of study was to evaluate the factors that determine the level of professional motivation of physicians to ensure the quality and effectiveness of respiratory care. Methods: A sociologic survey among primary care physicians (n = 460) in Amur and Yaroslavl regions of the Russian Federation was conducted by a specially developed questionnaire that has 45 questions. Among the respondents there were 89.3% of women and 10.7% of men. The method of Spearman's rank correlation and coefficients of conjugacy (К a is a coefficient of association and К к is a coefficient of contingency) were used for statistical analysis. Results: The question "Are you interested in providing high-quality care to patients?" was answered by 65.7 AE 2.2% of respondents positively, by 20.8 AE 1.8% negatively, and 13.5 AE 1.5% did not know how to answer. The degree of the positive motivation to provide high-quality and effective medical care was determined by the work experience and the level of professional qualification. There was found a correlation (r = -1.0) between the work experience and the specific weight of positive and negative replies to this question (К a = 0.821, К к = 0.371). The positive response was given by 95.5 AE 4.4% of physicians whose work experience was less than a 1 year and only by 58.3 AE 10.0% of physicians whose work experience was more than 20 years (p < 0.001). The same dependence is found between the degree of the motivation of physicians to high-quality and productive work and the level of professional qualification: experienced and high-qualified physicians have a decreased degree of motivation to work effectively (К a = 0.495, К к = 0.216). Conclusions: Motivation of physicians, focused on efficient and quality health care to respiratory patients, depends on the work experience and the level of professional qualification. This study was undertaken to assess the lung functions by spirometry; of an asymptomatic population who have been residents in the Delhi-NCR for at least two years aged between 18 to 25 years Methods: A volunteer population fulfilling the study criteria of age and length of stay (LOS) in Delhi-NCR were taken up for the study after informed consent. A proforma noting the demographics, bio-metrics, history of smoking, exercise, asthma and any other lung problem was recorded. Spirometry was performed on a portable sstandardised spirometer by experienced technicians and evaluated by a pulmonologist Results: A total of 679 volunteer students fulfilling the above criteria were eligible for the study after excluding smokers, asthmatics and those with other lung diseases. There were 52% females and 48% males, with an average age of 20.6 years and average LOS of 9.9 years in NCR. It was found that 38.46% had a perfectly normal spirometry. Another 45.05% had normal FVC, FEV1, FEV1/FVC ratio but either an abnormal (<75%) PEFR or FEF 25%-75% or both. Restrictive defect was seen in 3.5%, obstructive defect was in 1.9% and mixed defect in 10.98%. Conclusions: There is evidence of early lung damage in 45.05%, and more advanced lung damage in 16.38% among the asymptomatic young population exposed to high levels of environmental pollution. Background and Aims: Exposure to air pollution from combustion of fuel is a significant hazard to public health. Petroleum has detrimental effects on the respiratory functions of constantly exposed workers. Recently LPG is an alternative fuel source with the advantages of lesser cost and better safety profile. The study aims to measure the lung functions among taxi drivers of gasoline-based and LPG-converted taxi units. Methods: One hundred six taxi drivers were recruited over a 3-month period. Patient demographics, comorbid illnesses, smoking history and driving history were obtained through a questionnaire. Simple spirometry measured lung function. Association between driving history and lung function were analyzed. Background and Aims: The indices of population disease incidence are one of the most important indicators of public health as well as the level of organization and availability of medical care. The aim of the study was to evaluate regional features of the respiratory diseases (RD) incidence on the territory of the Far-East of Russia. Methods: The primary disease incidence and spread of RD with the application of materials of state statistical monitoring of RD on the territory of the Russian Federation (RF) for 1990-2014 were studied. Results: In the structure of the primary disease incidence, RD amount to 43.2% on the territory of the region. Conclusions: Statistical analysis of main indices of the level and dynamics of RD shows regional differences caused by nature and climate features and differences in the level of availability of medical services formed by the low motivation of population to apply to medical-prophylactic institutions about RD. Background and Aims: Wheat flour dust can cause occupational asthma (OA) in bakery workers. This study was designed to assess the relationship of wheat flour dust exposure and other factors such as age, history of atopy, nutritional status, occupation, personal protective equipment (PPE), smoking habit Methods: Cross sectional study with analityc descriptive was conducted on bakery workers who worked at production, warehouse, administrasion and marketing division for more than 1 year. Randomly,each sample will be examined by interview using questionnaire, physical examination, chest x-ray, spirometry, daily peak flow 3 times by peak flow meter in 2 weeks and wheat flour enzyme examination. Total sample is about 89 subjects and each subject will be followed within 2 weeaks. Results: Eighty nine subjects between 20 and 59 years old, Five subjects were indicated as OA (5,6%). spirometry result in 4 subjects is mild obstruction and 1 subject moderate obstruction (p = 0,020). PEF results in 5 subjects > 20% (p = 0,000) and supported by clinical symptoms of OA. Three subjects worked at moderate dust concentration and 2 subjects worked at mild dust concentration. SPT was found positive in 3 subjects with OA. Five subjects experience asthma symptoms. Enzyme result by spectrophotometry showed there was noamylase enzyme activity, but cellulose enzyme activity (1.5403u/g), protease enzyme activity (3.1566 u/g) and thiol (104,8281 pM/g) were found. Conclusions: There was no relationship between age, history of atopy, nutritional status, occupation, the use of PPE and smoking habit with OA incidence. Workers in production and warehouse division will be more likely to experience OA than workers in marketing and administration division. Positive SPT result was found in OA subject in production area. N. YUSRIL, A.D. SUSANTO, J. ZAINI University of Indonesia, Pulmonology and respiratory medicine-Faculty Of Medicine-Universitas Indonesia-Persahabatan Hospital-Jakarta, East Jakarta, Indonesia Background and Aims: Benzopyrene (polycyclic aromatic) is a carcinogenic agent found in cigarettes smoke. Benzopyrene metabolite (BPDE) is one of the benzopyrene metabolite. Kretek cigarette smoker is a person who smokes at least 1 cigarette per day for at least 1 year with no or less than 20% of amount and time of white cigarettes smoking. We investigated the level of serum BPDE in kretek cigarette smokers compared to non-smokers. Methods: This is a cross sectional study of which 15 "healthy" kretek cigarette smokers and 15 "healthy" non-smoker were enrolled in this study. We collected blood sample and we analyzed the BPDE level and also their exhale carbon-monoxide (CO) level during expiration. Serum BPDE level were assayed using ELISA kit. Background and Aims: The smoke from the forest fires has become one of the natural disasters that occurs annually in Riau especially Kampar. On august 2015, Kampar had 21 more hotspots than any other district in Riau. The aim of this study is to evaluate the expiration level of carbon monoxide in the population of people who have been exposed to smoke after the forest fires in Kampar (Riau) asscociated to respiratory complaints (such as coughing, coughing with sputum, shortness of breath and wheezing) and smoking habits Methods: The expiration level of carbon monoxide is measured using a CO analyzer from samples within the criteria, which have the age between 15-60 years old, did not smoke a cigarette in the last 12-24 hours, and has domiciled in the village of Rimbo Panjang, Kampar, in Januari 2016. For every 1 C rise, the risk of premature death among respiratory patients is up to 6 times higher than in the rest of the population. Air pollution exposure can trigger new cases of COPD and asthma. Increased exposure to allergens as a result of global warming, combined with exposure to pollutants that act synergistically to intensify the allergic response, could point to increased respiratory problems in the future. Extreme heat, droughts and floods increases morbidity of respiratory infection and mortality of chronic respiratory diseases. Influenza is greatly affected by temperature change, warm winters tend to be followed by severe and early-onset influenza incidence the following season. Epidemiological studies in Mozambique and Bengal documented increased incidence of respiratory infections after flooding. Respiratory infections caused 13% of all mortality rates following a Bangladesh flood in 1988. If the climate change results in more floods, acute respiratory infections may increase. Conclusions: Health effects of climate change include an increase in the prevalence of allergic respiratory diseases, exacerbations of COPD, respiratory infections, premature mortality. Methods: This study used NF-κB/luciferase transgenic mice, which carrying the luciferase gene under the control of NF-κB, to investigate the hypothesis that oral administration of LF could attenuate the systemic inflammatory response and organ damage after hyperoxia (FiO 2 > 95%) for 72 hours. After activation of NF-κB by hyperoxia, luciferase protein would have more expression. We could observe and analyze the luminescence excitation by non-invasive in vivo imaging system (IVIS) with injection of luciferin. The NF-κB/luciferase transgenic mice were assigned to four groups: (1) treated with water and room air, (2) Background and Aims: ARDS is associated with variable mortality, depending on disease severity, etiology and ventilator management. Methods: We conducted a retrospective study to determine 7-day and 28-day mortality, hospital length of stay (LOS) and duration of mechanical ventilation (MV) of ARDS-patients admitted in medical-ICUs at King Chulalongkorn Memorial Hospital between 2010 and 2014. Additionally, routine clinical practice and factors associated with poor outcomes were evaluated. Results: Of 167 ARDS-patients admitted in our ICUs, 13.17%, 46.71% and 40.12% fulfilled mild, moderate and severe ARDS-criteria, respectively. The main cause of ARDS was pneumonia. The 7-day and 28-day mortality were 29.2% and 64%, respectively with mean APACHE II-score of 26. The median LOS was 19 days and the median duration of MV was 11days. Pressure control mode was the most favorite mode(83.1%), used in the patients with average tidal volume of 8.7 ml/Kg IBW, plateau pressure of 31 cmH2O and PEEP of 10.3 cmH2O. Recruitment maneuver was most frequently used (45.5%) as an adjunctive intervention, whereas prone-position was applied to 5.1% of the patients. One-third of the patients received neuromuscular-blockades. The median 7-day fluid balance was +6177 ml. ARDS severity was associated with 7-day (p < 0.001), 28-day mortality (p < 0.001) and MV duration (p = 0.04). Multivariate analysis showed 7-day mortality was associated with tidal volume (p = 0.03), while 28-day mortality was associated with APACHE II-score (p = 0.007) and positive fluid balance in 7 days (p = 0.008). Conclusions: The 28-day mortality of ARDS was high, associated with disease severity. However, the average tidal volume, plateau pressure and fluid balance were greater than the protective limits. These findings indicated the potential improvement of ARDS outcomes in our hospital. There was no statistical difference in mortality between retrieval and non-retrieval cases. Conclusions: In our cohort of patients with ARDS supported with ECMO, the majority had severe pneumonia. Mortality did not differ based on site of initiation, and ECMO was associated with a lower than predicted mortality for patients with higher SOFA scores. N. YUANGTRAKUL 1 , P. WONGSURAKIAT 2 1 bangkok, Thailand, and 2 Mahidol university, Pulmonary medicine and tuberculosis, Bangkok, Thailand Background and Aims: There was evidence that patients with acute respiratory distress syndrome (ARDS) still had ventilator induce lung injury (VILI) despite keeping Ppl of 30 cmH2O or less. Stress index obtained from mechanical ventilator or computer program might be able to identify overdistention in many reports. Because stress index is calculated from the shape of the pressure-time (Paw-t) curve which we hypothesized that it could be estimated by visual inspection at bedside. We compared stress index value obtained from physician's visual inspection at bedside, with the value obtained using computer software. Methods: Two physicians would be asked to inspect Paw-t curve of the patient during volume control and constant flow wave form at bedside, while the waveform data was collected using Datalogger via Hamilton cable connected to the computer. The stress index was calculated using ICU-LAB software and categorized into 3 groups including < 0.9, 0.9-1.1, and > 1.1 represented 3 slope patterns by inspection (downward concavity, straight, and upward concavity respectively). The agreement between 2 methods were determine using weighted kappa analysis. Furthermore, we analysed stress index and agreement between different flow rate (40, 60, and 80 liter/min) Results: Eighty eight stress index value was obtained from computer analysis and 176 values from visual inspection. There was moderate agreement of stress index between visual inspection and computer software (kappa value = 0.497,P < 0.001). Sensitivity and specificity of stress index from visual inspection to identify overdistention were 93.75% and 89.38% respectively. Inspiratory flow rate 40 liter/min had been shown to have best agreement (kappa value 0.58, P < 0.001). We suspected the high inspiratory flow rate cause too short inspiratory time leading to inadequate inflation of respiratory system and mask overdistention in this group. Conclusions: Stress index by visual inspection has moderate correlation with computer analysis and could reliably identify overdistention in patient with acute respiratory distress syndrome. Results: Eight studies involving 3,823patients were finally analyzed, the total number of BL-M and BL-F group were 2,223 and 1,600, respectively. Although total mortality of BL-M group seems to be lower than that of BL-F group (19.9% vs. 26.8%), statistical significance could not demonstrated (risk ratio, 0.81; 95% CI 0.63 to 1.05; p = 0.12; I 2 = 63.0%). Also, 30-day mortality and ICU mortality in these patients were not significant different between two groups. BL-M therapy reduced length of total hospital stay compared to BL-F therapy (mean difference, −3.05 days; 95% CI, −6.01 to −0.09; p = 0.04; I 2 = 65.0%). However, there was no significant difference in length of ICU stay between two groups (mean difference, −0.32 days; 95% CI, −1.38 to 0.75; p = 0.56; I 2 = 0%) Our review revealed that none is well-designed, randomized controlled studies with large sample sizes. Conclusions: BL-M therapy tended to reduce total mortality and length of total hospital stay compared to BL-F therapy in patients with severe CAP. Further large-scale studies might be needed to reassess whether guideline-concordant combination therapies in these patients were adequate or not. Background and Aims: International survey demonstrated variable practice and responsibilities in mechanical ventilation and weaning in different countries. We aimed to evaluate these aspects in Thailand. Methods: A questionnaire was sent to Thai physicians who graduated from Chulalongkorn University via electronic mail to survey current practice and clinical responsibilities for mechanical ventilation and weaning in hospitals, including primary, secondary, tertiary and university hospitals. We analyzed data as numbers, percentages or proportions. Results: One hundred and thirty-eight physicians answered the questionnaire. Most of them were internists and sub-specialists, working at secondary and tertiary hospitals. Approximately, 67% of the responders had to take care of mechanically-ventilated patients in general wards. Around 33% of hospitals where the responders worked, nurses had authorities to initially set and adjust mechanical ventilation, while one-fourth of the hospitals, nurses played important roles in weaning, namely making a decision for weaning (23% of the hospitals), weaning termination (43% of the hospitals) and extubation (14% of the hospitals). Interestingly, from physician perspectives, nurses had moderate to high responsibilities for setting mechanical ventilation and weaning. For the weaning practice, 61% of physicians used weaning protocols and the others used spontaneous breathing trial-T piece and low level of pressure support, SIMV and closed loop modes for weaning. Rapid shallow breathing index was the most popular parameter used for predicting weaning outcomes. Approximately, 25% of physicians did not evaluate cuff leak test before extubation and noninvasive ventilation was one of strategies applied for prophylaxis of reintubation in 80% of the hospitals. Conclusions: Due to limited ICU resources, Thai physicians had to provide ventilatory care in general wards. Additionally, Thai nurses had significant responsibilities for ventilator management and weaning. Results: A total of 469 patients were included; 8 patients were excluded because they did not have an appropriate antibiotic prior to their mortality. Among the pathogens detected, a significant difference was found among the groups for the percentages of patients with the following: Acinetobacter species distributed in longer TSFAA groups (p = 0.024), The percentage of polymicrobial infections, multidrug-resistant organisms, and >2 infection sources was higher in the TSFAA 24-48 h group, as compared with groups with shorter time periods (all p < 0.001). The percentage of patients with prior antibiotic use was higher with a TSFAA of >48 h than with a TSFAA of shorter durations. In multivariate analyses, multidrugresistant organisms (MDRO), total days of previous antibiotics, Charlson comorbidity score, mechanical ventilation, and septic shock were significant characteristic factors for TSFAA (all p < 0.01). Conclusions: Previous antibiotic use, MDRO, comorbidity, mechanical ventilation, and septic shock may prolong (delay) the time from onset of sepsis to first appropriate antibiotic. Early inquiry these risk factors may help to select appropriate as soon as possible. Background and Aims: Although ATF3 participates in inflammation and ventilator-induced lung injury, whether it plays important roles in Pseudomonas aeruginosa(Pa)-induced ALI and the mechanism remains unclear. We therefore compared the response of ATF3 gene-deficient mice to wild-type mice in an vivo model of Pa-Induced ALI and in an vitro model of mouse macrophage RAW264.7 cells. Methods: RAW264.7 cells were cultured and then pre-incubated in presence or absence of siRNA ATF3 before exposure to Pa for 24 hrs. Pa were intranasally administered to ATF3 knock-out mice. Lung inflammatory injury and the underlying mechanisms for regulation of ATF3 on the Pa-induced ALI were subsequently determined. Results: ATF3 levels were increased both in RAW264.7 cells and lung tissues obtained from a mouse model of Pa-induced ALI. Pa-induced lung inflammation (neutrophils infiltration in the lung tissues, tumor necrosis factor α, interleukin 6), lung permeability (lung wet/dry weight ratio and bronchoalveolar lavage fluid (BALF) protein concentration) and mortality rates were attenuated in ATF3 knock-out mice. The inflammatory reaction (tumor necrosis factor α, interleukin 6) and apoptosis rates were reduced in ATF3 siRNA-treated RAW264.7 cells. Moreover, the role of ATF3 in Pa-induced ALI was partially restored by binding to lipopolysaccharide binding protein (LBP) confirmed by co-immunoprecipitation. Conclusions: These findings suggest that ATF3 protects against Painduced ALI via binding to LBP. Background and Aims: The protective lung ventilation strategy during one-lung ventilation provided beneficial effects in postoperative pulmonary complications. However, its effect in high risk patients undergoing lung surgery is not known. The aim of this study is to compare the effects of protective lung ventilation in high risk group with those in low risk group. Methods: Fifty two patients who were scheduled for an elective thoracoscopic lung surgery were enrolled. The participants were categorized according to the ARISCAT score (score ≥ 26 ; high risk group, score < 26 ; low risk group). During one-lung ventilation using double-lumen endobronchial tube, the ventilation strategy was composed of FiO 2 1.0, tidal volume 6 ml/kg and PEEP 6 cm H 2 O. The peak inspiratory pressure and plateau airway pressure and lung compliance were checked prior to the beginning of one-lung ventilation (T tlv ) and at 15-minute intervals (T 15 , T 30 ) during one-lung ventilation. Arterial blood gas analysis was performed at the point of time T tlv and T 30. The postoperative pulmonary complications were observed using chest x-ray and medical records within postoperative 72 hours. Results: The arterial oxygen tension at T 30 was significantly decreased in high risk group (228.3 AE 117.9 mmHg) compared with low risk group (307.8 AE 86.8 mmHg) (P = 0.011). However, there was no difference in peak inspiratory pressure and plateau airway pressure at T tlv , T 15 , T 30 between two groups. The static lung compliance was decreased in high risk group at T tlv , T 15 , T 30 . There was no difference in the incidence of postoperative pulmonary complications between the two groups. Conclusions: The protective lung ventilation strategy composed of FiO 2 1.0, tidal volume 6 ml/kg and PEEP 6 cm H 2 O is applicable to one-lung ventilation without increasing the plateau airway pressure in high risk patients. Background and Aims: Respiratory dynamics exhibits complex pattern of variations. Also, evidences suggest that the rate and volume of respiration can alter airway resistance and responsiveness to stimulation. Since airway hyperresponsiveness is a cardinal feature of asthma, we supposed that ventilation with variable tidal volume and respiratory rate can improve airway responsiveness in asthmatic rats. Methods: We initially recorded the respiration of control rats, as a variable respiratory pattern, using body box plethysmography. Animals were sensitized by ovalbumin according to the pattern of allergic asthma, and then ventilated with variable or constant breathing pattern for 60 min, using a Harvard Inspira ventilator. Variable breathing pattern was applied to ventilator by mean of an interface command in MATLAB. Finally, airway responsiveness to methacholine was compared in asthmatic animals ventilated with two different breathing patterns. Results: Normal rat breathing exhibited complex variability in both respiratory rhythm and volume. Compared to ventilation of the asthmatic rats with constant tidal volume and respiratory rate, variable ventilation with equivalent breath-breath minute volume decreased airway responsiveness to methacholine (F(1,10) = 4.3, p < 0.05). The breathing pattern is variable in nature and ventilation with this variable pattern can decrease airway responsiveness in asthmatic condition. Therefore, we suggest that variable ventilation, as a novel mode, may improve prognosis in asthmatic patients who need longterm ventilation. Background and Aims: Hypercapnic acidosis has been reported to protect against ventilator-induced lung injury (VILI), but to far, the underlying mechanism has not been fully investigated. Heme oxygenase-1(HO-1) is a fundermental endogenous adaptive mechanism to protect against cellular injury under various stress conditions. We have previously established that HO-1 play a remarkable protective role in VILI by virtue of the antiinflammatory and anti-oxidant actions. In the present study, we aimed to investigate whether the protective effect of hypercapnic acidosis against VILI was associated with HO-1. Methods: Rabbits were anesthetized, tracheotomized and received 4 hour volume-controlled ventilation. They were randomly allocated to one of the four following groups: low tidal volume (LVT) group, high tidal volume with normocapnia (HVT + NC) group, high tidal volume with hypercapnia (HVT + HC) group, high tidal volume with hypercapnia and HO-1 inhibitor ZnPP (HVT + HC + ZnPP) group. A gas mixture of carbon dioxide with oxygen (FiCO 2 4-5% or FiCO 2 12%, FiO 2 50%; balanced N 2 ) was administerd to maintain PaCO 2 in the NC (35-45 mmHg) and HC (70-100 mmHg). At the end of experiment, HO-1 protein expression and enzymatic activity were measured. Lung injury was assessed by histopathology, bronchoalveolar lavage (BAL) fluid protein content, neutrophil infiltration, lung wet-to-dry ratio, levels of inflammatory cytokines, and pulmonary oxidative reactions. Results: Injurious HVT caused significant lung injury, including increased histologic injury score, bronchoalveolar lavage fluid protein content, neutrophil infiltration and lung wet-to-dry ratio, as well as elevated inflammatory cytokines and oxidative reactions. Hypercapnic acidosis enhanced HO-1 expression and activity, and markedly reduced HVT-induced alterations. Treatment with ZnPP decreased HO-1 activity and partially reversed the protective effects of hypercapnic acidosis. Conclusions: The protective effect of hypercapnic acidosis on VILI was partially mediated by the anti-inflammatory and anti-oxidant properties of HO-1. Conclusions: This study further proves that the use of the RSBI rate, which is a dynamic measure of lung mechanics, is an accurate predictor of weaning outcome and even more reliable than other weaning parameters such as lung static and dynamic compliance and single RSBI determination. Background and Aims: Alveolar recruitment maneuver (RM) was reported to improve oxygenation in acute respiratory distress syndrome (ARDS) and may be related to reduced extravascular lung water (EVLW) in animals. This study was designed to investigate the effects of RM on EVLW in patients with ARDS. Methods: An open label, prospective, randomized controlled trial with ARDS patients was conducted in two hospitals in North Taiwan between 2010 and 2016. The patients were divided to two groups (with and without RM). The clinical values included arterial oxygen tension/fractional inspired oxygen ratio (PaO 2 /FiO 2 ) and EVLW index, duration of ventilator support, and mortality rate were compared between 2 groups. Results: Twenty-four ARDS patients on mechanical ventilator support were randomized to receive ventilator treatment with RM (RM group, n = 12) or without (Non-RM group, n = 12). Baseline demographic characteristics were similar between the 2 groups. Background and Aims: Ventilator associated pneumonia(VAP) is one of the most common fatal complications in mechanically-ventilated patients. Our hospital has closely monitored incidence of VAP and regularly launched preventive strategies to reduce the occurrence of this infection. However, the VAP rate was still high, especially in a medical intensive care unit(ICU). Methods: We retrospectively reviewed incidence of VAP in patients admitted in a medical ICU in King Chulalongkorn Memmorial Hospital between 2009 and 2015. Modified ventilator care bundle(VCB) was implemented in our ICU in April 1st, 2015. The bundle included 7 following issues: 1.) 5-moment hand washing, 2.) 30-degree of HOB elevation, 3.) maintained cuff pressure between 20-25 cmH2O, 4.) oral decontamination, 5.) nurse-driven weaning protocol, 6.) ventilator circuit care and 7.) promoting multidisciplinary team to coordinate VCB. We compared VAP rates before and after modified VCB application and evaluated factors contributing outcome-changes. Results: VAP rates before modified VCB implementation were high as shown in figure1. The bundle helped decrease the VAP rate to 6.9 occurrences /1000 ventilator-days, which was the lowest rate during a 7-year period. The major factors associated with this improvement were protocol-compliance, multidisciplinary team approach and more frequent cuff-pressure check. Nevertheless, the nurse-driven protocol played a minimal role in weaning. Figure 1 VAP rates before implementation Background and Aims: Mechanical ventilation is one of the most commonly applied interventions in ICU. Adaptive support ventilation (ASV) is a positive pressure mode of mechanical ventilation that is closed-loop controlled, and automatically adjusted based on the patient's requirements. In addition, the latest version of the Intellivent ASV has an automated SBT module (Quick Wean), which performs as SBT according to predefined criteria as soon as the level of assistance of the patient is low enough. Intellivent ASV has already been used safely for mechanical ventilation in passive and active patients with healthy lungs, in and after cardiac surgery, and with ARDS and/or with COPD. This article reports 3 cases in our department treated with mechanical ventilation by using Intellivent ASV. Case presentation Patient 1 was a 66-year-old female with a severe asthma attack accompanying hypercapnia, patient 2 was a 75-year-old female with acute exacerbation of interstitial pneumonia and patient 3 was a 70-year-old female with chronic lower respiratory tract infection due to NTM. All cases were required mechanical ventilation. Two patients were severely hypoxemic and one patient had severe hypercapnia. All patients received initial treatment of their primary disease and the mechanical ventilation was adjusted for their respiratory conditions. After the treatment, radiological findings, oxygenation and laboratory findings gradually improved. All cases survived without severe complications. Two cases had immediately successful weaning by using ASV, but one case had no success weaning by using ASV. This case required additional mechanical support because of muscle weakness. Conclusion: Intellivent ASV can be safely used during maintenance, or weaning phases of the mechanical ventilation with different lung conditions, therefore it use may be considered for our division. However severe respiratory failure due to chronic respiratory disease such as muscle weakness or chronic type 2 respiratory failures needs particular attention. Introduction: Bee-sting causes various reactions. Acute respiratory distress syndrome(ARDS) and cardiac dysfunction following bee-sting is relatively uncommon. We reported a case of anaphylactic shock with ARDS and stress-induced cardiomyopathy after multiple bee-stings. Case presentation: A 79-year-old woman was admitted in our intensive care unit(ICU) due to bee-anaphylaxis. The patient unluckily got over 100 bee-stings 30 minutes before admission while she was walking in a park. A swarm of bees attacked her after a honeycomb fell from a tree on her head. After stung, she was immediately sent to our hospital. At an emergency department, she developed hypotension, facial angioedema, expiratory wheezing in both lungs and oxygen desaturation. Additionally, her skin revealed uncountable sting-marks. She was diagnosed with severe anaphylactic reaction and received injections of antihistamines, steroids, and epinephrine plus nebulized bronchodilators. Besides, the stings on her skin were removed as much as possible. Despite providing the treatment, she still had difficulty breathing and became respiratory failure. Her chest radiography showed bilateral diffuse alveolar opacities with mild cardiomegaly as shown in figure 1 . Consequently, she was assisted with invasive mechanical ventilation and then transferred to the ICU. At the ICU, additional investigations were performed to evaluate causes of pulmonary edema. Electrocardiography revealed sinus tachycardia with early repolarization and minimal ST-elevation at lead I and aVL. Echocardiography demonstrated mildly impaired systolic function(LVEF 50%) with apical ballooning. Nevertheless, inferior vena cava(IVC) did not dilate and IVC distensibility index was less than 13%. Serum tryptase was high. These findings were compatible with anaphylaxis complicated with noncardiogenic pulmonary edema and stressinduced cardiomyopathy. As a result, lung protective strategy and standard treatment for anaphylaxis were applied. Finally, she recovered uneventfully and was extubated at the 5th day of admission. Results: Conclusion: This case demonstrated the uncommon severe reactions from anaphylaxis and massive bee-envenomation. Background and Aims: Teratomas arising entirely from within the lung is an extremely rare entity with less than 60 reported cases worldwide since it was first described in 1839.We present a case of a 22-year old female who was diagnosed with intrapulmonary teratoma after presenting with hemoptysis. This case highlights the importance of a combination of diagnostic tools to arrive at a correct diagnosis and timely treatment of a potentially curable benign intrapulmonary mass to prevent further fatal complications and morbidity. Methods: A 22-year old female came in for a 5 year history of chronic cough and recurrent hemoptysis. Imaging studies show a heterogenous mass located at the right upper lobe, with nodularities and calcifications. Bronchoscopy was done which revealed strands of hair arising from the right upper lobe. A lobectomy was then performed, which showed that the entire right upper lobe was converted to a large mixed solid-cystic mass with sebum, teeth and hair strands. It was histopathologically confirmed as mature teratoma of the lung. Results: Mature teratomas are often abdominal in location, and may occasionally be seen in the thoracic area, usually anterior mediastinum. A purely intrapulmonary teratoma is an extremely rare entity. Our case may have been the largest intrapulmonary mature teratoma, measuring 15 x 9 x 5 cm. Conclusions: This case highlights the importance of a combination of imaging and bronchoscopic modalities to diagnose a benign lung neoplasm with a good chance of successful cure. Background and Aims: Technical developments in the field of pediatric bronchoscopy have expanded the diagnostic possibilities of this procedure while, at the same time making it less invasive: Today, almost all such examinations can be carried out on an outpatient basis and flexible fiberoptic instruments can be used in children who have reached school age with only analgesia and sedation. Technical innovations include endoscopic laser surgery, for example, to treat subglotic hemangiomas even in very young infants and bronchial balloon dilatation for airway stenoses. These developments have improved and rendered less stressful the diagnosis and treatment of airway and pulmonary problems in children. Methods: In Retrospective study during one year period a total of 875 children (543 males and 332 females) with respiratory diseases who were aged from 10 days to 20 years, were examined and/or treated by bronchoscopy (including bronchoscopic intervention) under sedation and local anesthesia. Results: The flexible fiberoptic bronchoscopy was more useful tool in evaluation of patients with noisy Breathing (stridor, persistent wheezing), persistent atelectasis and non-resolving Pneumonia, mucosal deplugging, suspected foreign body aspirations, Bronchial stenosis and for patients who had tracheostomies. Conclusions: The high diagnostic and therapeutic yields with very low complication strongly support the use of the flexible fibroptic bronchoscopes in the diagnostic evaluation of infants and children who have a variety of pulmonary problems. Background and Aims: Flexible bronchoscopy increased risk of hypoxemia in patients who had baseline impaired lung function. Oxygen cannula was routinely used during procedure, however desaturation occasionally occurred. High-flow nasal cannula (HFNC) deliver higher FiO 2 that provide benefit alternative to conventional oxygen cannula. Objective: The aim of this study was to compare PaO 2 during bronchoscopy while using HFNC and conventional oxygen cannula. Methods: 24 patients were assigned to receive either HFNC (HFNC group) or conventional cannula (control group). ABG were collected for 4 separated times (T 0 = before bronchoscope, T 1 = 15-minute after bronchoscope was inserted through the vocal cord, T 2 = at the end of procedure and T 3 = 15-minute post procedural period with continuation of oxygen therapy). Results: Among 24 patients, 12 patients in HFNC group. PaO 2 were shown non-significant difference in both groups. PaCO 2 in control group were shown tend to increase and significant more than HFNC group. Finally, HFNC group shown significant more FiO2 than control group. Conclusions: The application of HFNC during bronchoscopy may be useful in selected patients especially more severe hypoxemia and hypercapnic risk. Background and Aims: Fibreroptic Bronchoscopy(FOB) is a common invasive investigation in the field of respiratory medicine. Patients undergoing FOB report varied experience with regard to anxiety levels, awareness about the investigation and the comfort levels during the procedure. This study aims to determine the lived experience of all patients undergoing FOB. Methods: A qualitative research design was used. Patients >18 years of age who have undergone FOB for the first time were included and in depth interviews were taken in a language comfortable to them. Once data saturation was achieved, that is no new information or ideas can be derived from patients, it was understood that the adequate sample size has been reached. Focused group discussions (FGD) were then held after selection of patients by purposive sampling health care providers. The investigators conducted the discussion with scripted questions which was answered by all participants with an investigator guide. FGD and in depth interviews were held at a convenient place to the participants and they were provided with a snack and drinks later. Data analysis will be done by N-VIVO software. Main themes will be identified and categorized. Results: Since this is an ongoing study the results have to be analysed and will be discussed in the conference later. Conclusions: After the analysis, the experiences of patients undergoing FOB and their awareness will be summarized. Background and Aims: Cases of foreign body lodged in airways are not uncommon especially in children. The removal of foreign body usually can be successfully done using a flexible bronchoscope with various extraction devices. Rigid bronchoscopy is reserved for challenging cases. Results: We present a case of a dislodged tooth result of a motor-vehicle accident involving a 25-year-old man. Initial attempts to remove the tooth with flexible bronchoscope and cryoextraction were futile. The tooth was successfully removed with rigid biopsy forceps introduced via a rigid bronchoscopy after cyro-reduction done on the surrounding granulation tissue that embedded the tooth within the airway lumen. Conclusions: Flexible bronchoscopy remains the procedure of choice for foreign body removal owing to its wide availability. However, rigid bronchoscopy provides additional option for challenging cases in institution where such facilities are available. Background and Aims: Aim: To evaluate the usefulness and safety of EBUS-TBNA in patients undergoing this procedure in differentiating sarcoidosis from other diseases. Methods: Methods: We investigated retrospectively the usefulness and safety of EBUS-TBNA in all patients undergoing bronchoscopy who were suspected with sarcoidosis since the introduction of EBUS-TBNA in our hospital. Results: Results: All patients underwent bronchoscopy with a 22-gauge needle under laryngeal anesthesia.38 patients received BF due to suspected sarcoidosis; All patients underwent BAL and TBLB. Of all, 12 patients received additional EBUS-TBNA. EBUS-TBNA was conducted in all patients without evident accidental symptoms, although the maximum short-axis diameters for lymph nodes in those patients were 5-21.6 mm, which tended to be smaller than those in the previous reports. 24 were diagnosed with sarcoidosis; of all, 9 underwent EBUS-TBNA. 5 were diagnosed with other diseases; 10 were unknown. We obtained findings in 19 of 24 cases for BAL, 11/24 for TBLB and 7/9 for EBUS-TBNA among procedures conducted. TBLB positive tended to have higher lymphocyte counts in BAL fluid (TBLB positive 44.70 AE 5.4781 versus TBLB negative 38.04 AE 4.81, P = 0.18). with no significant difference. Also, there was no definite difference in pulmonary lesions and CD4/8. Conclusions: Conclusions: EBUS-TBNA was more useful in differentiating sarcoidosis from other diseases compared to TBLB. The study findings indicate that the procedure can be conducted safely without accidental symptoms even in relatively small lymph nodes. We will publish details of the study results at the 21th congress of the APSR. Background and Aims: The quantitative bacteriologic methods have increased the reliability of sputum specimens for the diagnosis of lower respiratory tract infections. Our study was designed to compare the diagnostic yield of Deep Tracheal Aspirate with BAL samples of patients with Pneumonia in a Tertiary Care Hospital, to analyse whether deep endotracheal aspirate can be used to substitute BAL as a less expensive and less invasive means of obtaining specimen for culture for diagnosing pneumonia. Methods: We conducted prospective comparative study on 100 patients in ICUs and HDUs who were intubated or tracheostomised and showed signs of pneumonia. In each patient two samples were collected: ET aspirate and Bronchoscopic BAL samples. The suction catheter were introduced through the ET and advanced beyond the carina, to collect the lower respiratory tract secretions into a mucus trap. The fiberoptic bronchoscope were introduced and advanced to the bronchial orifice selected based on the radiographic location of the new pulmonary infiltrate. BAL was performed by instilling 100 ml sterile, normal saline. A quantitative culture of BAL/endotracheal aspirate was done according to standard protocol. Results: ET culture showed a 77% frequency of growth whereas BAL showed a 95% frequency. Out of the various organisms isolated, Acinetobacter was seen most frequently in both the methods with a frequency of 36% via ET and 39% via BAL. Klebsiella (16% in ET and 21% in BAL) was the second most common organism to be isolated followed by Pseudomonas (14% in ET and 23% in BAL). However, in comparison, between the overall frequency and the different isolates, the p value was found to be >0.05 which was statistically not significant. Conclusions: These results demonstrated that ETA and BALF Gram stains & cultures are not interchangeable and that ETA is an acceptable alternative to bronchoscopy for the evaluation of suspected pneumonia. Background and Aims: We describe a unique case of an inhaled foreign body, a 3.5-cm-long piece of a chopstick, which had been overlooked for 2 years. Methods: A 78-year-old woman was admitted to our hospital because of refractory pneumonia. She had been hospitalized repeatedly for recurrent pneumonia in the left lower lung and had a 2-year history of hemoptysis. Chest computed tomography (CT) showed parenchymal consolidation in the posterior segment (segment 2) of the right upper lobe. The patient opted for surgical treatment, rather than other interventions, because she had refractory pneumonia. Results: A right upper lobectomy was performed. The resected specimen revealed obstruction of the posterior segmental bronchus (B2) of the right upper lobe, in which a foreign body was found embedded in granulation tissue. The foreign body was a 3.5-cm-long piece of a chopstick. After further questioning, the patient remembered aspirating the chopstick while eating several years earlier. As it is difficult to remove a long-standing intrabronchial foreign body, we recommend surgical treatment. Conclusions: To our knowledge, this is the first case presented in the English literature of a foreign body that was a piece of a chopstick that had been undetected for more than 2 years. Background and Aims: Tracheobronchopathia osteochondroplastica (TPO) is a rare benign disorder characterized by multiple sub-mucosal osseous and cartilaginous nodules arise from the trachea and major bronchi with sparing the posterior membranous part. This condition is usually asymptomatic and/or nonspecific respiratory symptom such as chronic cough, wheezing, recurrent respiratory tract infections and occasionally hemoptysis. In this study, the first case of TPO complicated with fungal and tuberculosis co-infection in Thailand was thoroughly described. Results: Case presentation: A 53-year-old female presented with chronic productive cough and significant weight over two months. Her chest radiograph showed reticulonodular opacity at RUL and RLL and sputum acidfast bacilli had been negative for 3 consecutive days. The chest CT scans demonstrated multiple small submucosal nodules with calcification at tracheal wall and bronchial wall, tree in bud appearance and small areas of peribronchovascular consolidation scatter in both lungs. To evaluated the nature of lesions, Flexible Bronchoscopy was performed and multiple irregular nodules protruding into the tracheal lumen were visualized. The nodules were distributed along anterolateral wall of trachea and both main bronchi. Histopathological exam revealed inflamed bronchial tissue with presence of fragments of osseous tissue in bronchial submucosa. The evidence pointed towards a diagnosis of TPO, However, the clinical symptom possibly from superimpose infection. Fungal hyphae were detected in a special stains of bronchial washing fluid and Aspergillus fumigatus was identified subsequently. Furthermore, bronchial washing fluid for Gene Xpert was positive. The patients was treated with antifungal and antituberculosis regimen. At the 3 months follow-up, the patients reported relief of her symptoms and the chest radiograph showed slight improvement. Conclusions: TPO is a rare condition which present with nonspecific symptoms. Patients with a chronic cough should not be given a presumptive diagnosis with common diseases. Further investigation for definite diagnosis should be considered. showed the utility of low-dose CT screening, the detection rate of diagnosing Non-solid lesions (NSLs) has increased. Although we previously reported the effectiveness of diagnostic bronchoscopy for NSLs, the predictive factors have not been investigated. Methods: Consecutive patients who underwent diagnostic bronchoscopy for NSLs at our institution from September 2012 to January 2016 were enrolled. Among these, cases that were performed with radial endobronchial ultrasound (radial EBUS) and finally diagnosed as lung cancer were included in this retrospective study. They were reviewed and analyzed to examine the association between the diagnostic yield and the clinical factors as follows; location (central, internal or peripheral), consolidation-totumor (C/T) ratio (over 25.0% or not), size (over 20 mm or not), biopsy times (over 5 or not), using of guide sheath (using or not), the visibility on chest X-ray (fine or not), using of virtual bronchoscopy (VB) (using or not), and the bronchus sign on thin-section CT (positive or negative). Results: We enrolled 242 cases and 156 were diagnosed by this procedure, so the diagnostic yield was 64.5%. In the univariate analysis, the positive bronchus sign was a significant factor for higher diagnostic yield (71.8% vs. 34.0%; p < 0.001). Using of VB tended to have higher yield, but there was not significant difference (66.8% vs. 53.5%; p = 0.138). Conversely in the multivariate analysis, the positive bronchus sign and using of VB had significant relationships with higher diagnostic yield (p < 0.001, odds ratio: 4.900 and p < 0.001, odds ratio: 1.720, respectively). The positive bronchus sign on thin-section CT and using of VB were the positive predictive factors of diagnostic bronchoscopy for NSLs. Background and Aims: Foreign body aspiration is uncommon among adult population with an estimated incidence of 0.2% to 0.33% of all bronchoscopies performed. However, it can be life threatening and most common cause of death in unexpected accident in Japan. Methods: A 38-year-old healthy man caused pulmonary arrest after drinking a large amount of alcohol. When the patient brought to our hospital, he underwent cardiopulmonary resuscitation by emergency medical services. Fortunately the patient reverted to sinus rhythm with good cardiac output, and was performed endotracheal intubation. The patient was hospitalized immediately in intensive care unit, but could not be maintained oxygen saturation although he was on artificial ventilator. We suspected the exist of lodged foreign body, according to abnormal findings of closing the left main bronchus on the chest CT scan images, and tried to dislodge them by using flexible bronchoscopy after waiting for the increasing of oxygen saturation. Results: There was no obvious finding in the right main bronchus, in contrast, pieces of meat-like matter that can completely lodge the left main stem bronchus were there. To remove the foreign bodies, the patient underwent bronchoscopy using grasping and basket forceps, and those were removed completely. After these procedures, the patient was weaned from artificial ventilator because of markedly improving of oxygenation and level of consciousness, in 2 days in the hospital. The patient went on to have an excellent clinical recovery, despite the existence of atelectasis and aspiration pneumonia, and was discharged after 7 hospital days. We report the case that was able to rescue by rapid removal of foreign body Background and Aims: Sclerosing pneumocytoma (hemangioma) is a rare benign epithelial tumor of the lung, possibly related to the pulmonary epithelium (type II pneumocyte).A thoracotomy is usually indicated for definite diagnosis and treatment. Rarely, the diagnosis was made using TBNA. We present a case that was diagnosed via using of radial probe endobronchial ultrasound (R-EBUS) and transbronchial needle aspiration (TBNA). Methods: A 28-year-old woman was referred for asymptomatic right upper lung nodule on chest radiogram. Thorax computed tomography revealed a contrast enhanced, well-circumscribed, round mass in the upper lobe of the right lung (Fig 1) . Radial probe endobronchial ultrasound (R-EBUS) with transbronchial nodal aspiration (TBNA) was performed. Results: The pathologic examination revealed atypical cells suspicious of sclerosing pneumocytoma. Immunohistochemistry stains show reactive with TTF-1, cytokeratin (AE1/AE3) and EMA is expressed by luminal cells (Fig 2) . They are negative for synaptophysin. Pulmonary sclerosing pneumocytoma was diagnosed. Conclusions: Conclusion, we present a case that was diagnosed via using of endobronchial ultrasound and TBNA. Although data is limited, endobronchial ultrasound and TBNA can be an alternative method for diagnosis of such rare lung tumor. Background and Aims: Asthma is considered a major health problem in Sri Lanka as well as globally. The burden of asthma is overwhelming. Asthma control has not been formally evaluated in Sri Lanka. This study has comparatively evaluated disease control with Asthma Control Test (ACT) and peak expiratory flow rate (PEFR). Methods: Asthma control was examined in a cross-section of 449 asthmatics above 5 and below 70 years of age using the ACT, and on the PEFR % predicted. Scores below 20 on the ACT and PEFR below 80% predicted indicated uncontrolled asthma. Simultaneously, patients were clinically evaluated, whether their asthma was controlled or uncontrolled. Asthmatics were again evaluated fortnight after treatment according to Global Initiative for Asthma (GINA) guidelines in two primary care clinics in Sri Lanka. Background and Aims: Asthma is a common chronic respiratory disease. There are approximately 300 million asthmatic persons worldwide with 250,000 death annually due to asthma which are mostly preventable. World Health Organisation (WHO) estimates that in 2025, there will be 100 million increase in asthmatic patients. In Vietnam, in 2012, a crosssectional study on asthma in adults showed the incidence was 4.1%. For asthma controlling situation, in 2003, a report of physicians about controlling asthma cases in several cities of 8 Asia-pacific countries -AIRIAP (Insights and Reality in Asia-Pacific) (including Vietnam: Hanoi and Ho Chi Minh city) showed a result of poor controlled asthma. Three major concerns as important causes of poor controlled asthma include: treatment non-compliance, difficult to approach essential drugs and exposure to triggered agents. The purpose of this work is to perform a practical approach related to the diagnosis, the assessment and the treatment of asthma. Methods: Expert opinion and evidence-based guidance Results: In most of cases, asthma can be easily diagnosed basing on history, clinical presentations and treatment response. Asthma treatment basically depends on anti-inflammatory inhaled corticosteroid and bronchodilators. Effective asthma management (or asthma control) mostly relates to treatment adherence of patients, appropriate drug use. Thus, it is very important for physicians, especially those who works in primary health care centers, to monitor, assess levels of control and consult for patients. While most of asthmatic cases can be controlled by routine therapy, some cases do not respond to treatment due to pathology characterized by uncommon inflammatory basis (non-atopy, tendency of chronic changed lung structure) or comorbidities. These cases should be referred to respiratory specialized centers to examine, diagnose, assess asthma severity and build up treatment plan. Background and Aims: The study aims to investigate the effects of tradinterol (SPFF) on proliferation and [Ca 2+ ] i elevation induced by platelet derived growth factor (PDGF) in rat airway smooth muscle (ASM) cells. Methods: PDGF was exposed to the rat ASM cells for 48 h after they were pre-treated with SPFF. Cells cycles were determined by flow cytometry to evaluate the effect of SPFF on the proliferation of the cells. The suppressive effect of SPFF on the elevation of [Ca 2+ ] i induced with PDGF was detected by the flow cytometry. SOC inhibitors such as SKF-96365, NiCl 2 and 2-APB were respectively used as a pharmacological tool to investigate the possible mechanism. The gene expression of Stim1 and orai1 in the cells was measured by Real-time PCR after they were exposed to PDGF and pre-treated with SPFF. Results: It is showed that the drug suppresses the increase of [Ca 2+ ] i in the cells induced by PDGF in a dose-dependent manner. SPFF(10 −6 mM) significantly decreases the increase of [Ca 2+ ] i induced by PDGF, which is similar to the effects of the SOC inhibitors. The suppression of the combination of SPFF with the specific SOC inhibitors is almost same with that of the SOC inhibitors used alone, which indicates that SPFF and SOC inhibitors maybe have similar mechanism of action. Moreover, determination by the flow cytometry illustrated that the proliferation of ASM cells promoted with PDGF was inhibited by SPFF and the concentration of 40 μM had a maximal efficacy. What's more, SPFF was found to suppress significantly the increased mRNA expression of Stim1 and Orai1 in the cells stimulated with 25 ng/ml of PDGF. The findings suggested that SPFF could inhibit the proliferation of rat ASM cells induced with PDGF and the mechanism might be associated with the [Ca 2+ ] i /Stim1/Orai1 signaling pathway. Background and Aims: Asthma, a well-knownchronic inflammatory disease, is extensively studied for many years and completely curing asthma is still a big challenge. Protein acetylation, especially histone acetylation plays a significant role in anti-asthma processes. Histone deacetylation inhibitor (HDACi) also has an ideal curative effect to asthma in clinical practices. In order to reveal the molecular level relationship between protein acetylation and anti-asthma processes, and provide novel molecular targets for asthma treating, we studied proteomic and acetylproteomic changes in healthy and asthmatic cells in mouse lung. Methods: BALB/C mice were divided into two groups, control group and asthmatic model group. Twenty-four hours after OVA nebulization, lungs tissue from each group were taken out and extracted the protein. Then acetylpeptide samples enriched, stable isotope labeled, HPLC fractionated the peptides, and then sent to LC-MS/MS. At last, quantification information was acquired and bioinformatics analysis was performed. Results: A total of 5346 proteins and 581 acetylation sites were identified, among which 154 proteins and 68 acetylation peptides were significantly changed respectively. Many activated and deactivated processes, pathways and protein groups were identified through bioinformatics analysis. P300 and its associated network was identified to be responsible for anti-asthma process. Sequence motif preference under asthma condition was revealed and a novel Kac related core histone motif, −KAXXK-, is identified as a key regulate unit through data comparison. Conclusions: Acetylation modification plays an important role in the pathogenesis of asthma, especially a Kac pattern, −KAXXK-, may play fatal roles in OVA induced asthma. These findings will be a contribution to discovery of the self-recovery mechanism of asthma in young kids, and will also be useful for adult asthma treating. Background and Aims: Asthma is a chronic obstructive disease which is characterized by recurring airway inflammation, reversible airway obstruction, airway hyperresponsiveness and airway remodeling. Thymoquinone (TQ), an active ingredient isolated from Nigella sativa, was reported to exhibit anti-inflammation and anti-proliferation of in various cancer cells as well as epithelial cells. The aim of this study was to evaluate the effect of TQ on the inflammation, neoangiogenesis and remodeling of airway blood vessels induced by Ovalbumin (OVA) in asthma mice. Methods: Wild-type BALB/C mice were divided into five groups: control, OVA group (asthma), OVA + TQ group, TQ group, OVA+ dexamethasone (DEX) group. Airway inflammation was assessed by HE staining, AB-PAS staining and ELISA. The neoangiogenesis and remodeling of airway blood vessels were assessed by Western Blot, RT-PCR, Immunohistochemistry and Immunofluorescence. Results: Our results revealed that TQ inhibited the production of inflammatory factors IL-4/-5. Immunohistochemistry analysis showed that the increase of CD31 and α-SMA expression in asthma mice challenged by OVA was suppressed by TQ. Moreover, Western blot and Immunohistochemistry analysis also showed that PI3K-Akt-VEGF pathway was downregulated while the down-regulation of Slit-2 was increased by TQ. Meanwhile Immunofluorescence analysis showed that Slit-2 and Robo-4 were co-expressing after TQ treatment in OVA-challenged asthma mice. Conclusions: Our study demonstrates that TQ attenuated the inflammatory reaction by antagonizing IL-4/-5, while the anti-neoangiogenesis effect of TQ is mediated by inhibition of VEGF expression through PI3K/ AKT signaling pathway, which supports a potential role for TQ in ameliorating asthma in mice. Background and Aims: It is worthy to hold steady for patients with asthma remission and avoid relapse. Astragaloside IV (AS-IV), an important derivative of the Chinese herb astragalus membranaceus, has been demonstrated to have antiasthmatic effects. However, it remained unclear whether AS-IV used in asthma remission could alleviate airway inflammation during acute episode. This study was aim to investigate the preventable effects and mechanisms of AS-IV, compared to rapamycin, in asthma remission on airway inflammation in vivo. Methods: BALB/c mice were sensitized to ovalbumin (three i.p. injections) and challenged by ovalbumin for 1 week. After 3 weeks of rest/recovery, mice were re-exposed to ovalbumin for 1 week. Mice were treated with AS-IV or rapamycin during last 4 weeks. Characteristic features of allergic asthma, including airway hyperreactivity (AHR), airway histopathology, and cytokines (IL-4, −5, −13 and INF-γ), CD4 + T and CD4 + CD25 + Foxp3 + Treg cells in bronchoalveolar lavage fluid (BALF) were examined. Downstream proteins of mTORC1/2 signaling pathway were also assessed. Results: Both rapamycin and AS-IV markedly decreased inflammatory infiltration in the lung tissues. Rapamycin also suppressedCD4 + T cells and CD4 + CD25 + Foxp3 + Treg cells in BALF, although IL-5 was augmented and no effect on AHR was observed. AS-IV also reduced IL-4 and IL-5 levels, but had limited effects on AHR and CD4 + T and CD4 + CD25 + Foxp3 + Treg cells. Both drugs inhabited phosphorylation of the S6 ribosomal protein, which is downstream of mTORC1, however, no effect on akt (S473) phosphorylation, the downstream of mTORC2, was observed. Conclusions: We concluded that the antiasthmatic effects of AM are at least partially through modulating mTORC1 signaling pathway. Treatment with AS-IV during asthma remission may have preventable effects for the disease control. Outpatients who meet all of the following criteria were recruited: 1) aged ≥ 14 years; 2) resided in the study city for at least 2 years; 3) had an asthma diagnosis for at least 3 months according to the GINA criteria. Information of demographics, asthma control, asthma management, asthma attacks and self-management, disease perception was collected during face-to-face interview. An Electronic Questionnaire Data Capture(EQDC) system was employed for data input. Continuous variables were presented as mean AE SD and categorical variables were presented as frequency. Results: Altogether 3,875 cases were included, of whom 2,347(61%) were women. The total asthma control rate of 2016 in China was 28.3%, while asthma control rate of the 10 cities which took part in the asthma control investigation in 2008 was 39.0%. Hospitalization rate due to asthma exacerbation was 26% while emergency visit rate was 22%. Only 10% of the patients use peak flow meter for monitoring. 55.4% of the patients select ICS + LABA as daily regular used control medication, while 18.8% use leukotriene modifiers and 10.6% use ICS. As for asthma attack frequency, 10% of the patients had symptoms every week, while 17% never experienced asthma attack during the past year. 82% of the patients had symptoms during asthma attack, the most common symptoms were: cough (66.9%), chest tightness (65.4%) and shortness of breath (60.0%). 69% of the patients had right perception on the nature of disease. Conclusions: Despite improvements in asthma control compared to investigation in 2008, regional difference and disproportion was obvious. There's still a gap between the proportion of asthma control in China and goals set in GINA. Background and Aims: Background: The aim of asthma management is to achieve better asthma control. Asthma control measure includes various clinical and functional manifestations. It is still a debate whether a better control of asthma translates into better quality of life. Aim: To evaluate the association between asthma control and asthma related quality of life. Methods: Uncontrolled and partly controlled asthma patients attending pulmonary medicine clinic were recruited for the study. Physical characteristics, socio demographic data and lung function results were obtained. Asthma related Quality of Life questionnaire (AQLQ) and Asthma Control Questionnaire (ACQ) were administered for the study subjects as per their preferred language. Correlation between asthma quality of life, the pulmonary function parameter (FEV1&PEFR) and asthma Control (ACQ) was determined by using the Pearson correlation coefficient. Chi-square test was done for the categorical variables like age distribution, gender etc. P-value, P ≤ 0.05 was considered significant. Results: Among the 83 study patients (36 females and 47 males), 32 (38.5%) were partly controlled asthmatics and 51 (61.5%) were uncontrolled asthmatics (GINA 2014symptom domain). The mean age and BMI were 42.93 and 25.07 respectively. There were nine smokers (10.8%), nine allergic rhinitis patients (10.8%) and 17 GE Reflux Disease patients (20.4%) in the group. Mean PEFR% and FEV1%(Pre bronchodilator) were 71.02 and 58.58 respectively. There was a moderate negative correlation between ACQ and AQLQ (r = −0.589: P = 0.00) and a weak correlation between FEV1 and AQLQ (r = 0.23: P = 0.03). A weak correlation was also found between number of symptoms and AQLQ score (r = 0.390: P = 0.00) (Pearson Chi square method P = 0.009). Age, BMI, co-morbidities and PEFR had no association with quality of life (AQLQ).Conclusions Asthma control measure (ACQ) predicted asthma related quality of life better than other variables. Background and Aims: Cough is one of the most common symptoms at outpatient department and has great negative impact on their quality of life. Asthma is one of the most common causes of cough, however, it is often difficult to diagnose accurately. Therefore, there is a pressing need for a novel tool for the diagnosis of asthma in patients with cough. In the present study, we evaluated our original questionnaire and laboratory findings, and then developed a diagnostic scoring system for asthma in patients with cough. Methods: We retrospectively analyzed the medical records of patients who attended our outpatient department with the chief complaint of subacute or chronic cough and answered to our original questionnaire from April 2014 to March 2016. We evaluated a correlation of each question items and the final diagnoses, and identified the factors contributing to the final diagnosis of asthma. Results: In total, 205 patients were included into the final analysis: median age of 53 years old, 102 female (49.8%), 106 patients with chronic cough (51.7%). Final diagnoses were as follows: asthma (n = 91, 44.4%), GERD (n = 46, 22.4%), post-infectious cough (n = 41, 20.0%), rhinosinusitis (n = 38, 18.5%), atopic cough (n = 31, 15.1%), and others (n = 22, 10.7%). Five question items: wheezing, night or early morning cough, past history of asthma, past history of respiratory diseases, and living in not wooden house predicted asthma as final diagnosis. We then developed a diagnostic scoring system for asthma consisted of these question items and exhaled nitric oxide levels. The areas under the curve of the diagnostic scoring system was 0.799 (95% CI, 0.717-0.881). Conclusions: We developed the diagnostic scoring system composed of six factors for asthma in patient with subacute or chronic cough. This may aid improving diagnostic yield for asthma. Background and Aims: Control of asthma depends on various factors, including the cooperativeness. Cooperativeness is a complex concept that includes the patient's readiness to follow the doctor's recommendations (compliance), carrying out of the doctor's recommendation within a particular treatment or drugs (adherence), patient's awareness of the disease, opinion about the disease, the character and availability of the therapy, satisfaction from the cooperation with the doctor, and sincerity. The aim of the study was to estimate the relationship between asthma control with the level of cooperativeness and depression in patients. Methods: 141 patients with asthma (76% were women) at the age of 18-60 were examined. The Asthma Control Questionnaire 5 items-selfadministered (ACQ-5), the questionnaire "The estimation of cooperativeness in asthma" (ECA, L.V. Bogovin et al., 2015) and "Center for Epidemiologic Studies Depression Scale" (CES-D, M.M. Weissman et al., 1977) were used in the study. Results: 36 patients had the controlled asthma according to the ACQ-5. Of these, 19.4% had mild asthma and 80.6% -moderate asthma. 75% of this group had a positive cooperativeness by ECA questionnaire. 105 patients had uncontrolled asthma (20% mild, 55.2% moderate, and 24.8% severe asthma). 98 patients (93%) partly or completely did not follow the recommendations of the physicians and had negative cooperativeness (χ 2 = 68.4; p < 0.001). Group of patients with controlled asthma compared with uncontrolled asthma more frequently showed the absence of depression by CES-D test: 89 vs. 60% (χ 2 = 10.18; p < 0.01). The remaining 11% of the group showed only mild depression. Patients with uncontrolled asthma often showed the presence of depressive symptoms (χ 2 = 8.1; p = 0.004), mild (36%) and severe (4%) degree. Furthermore, the degree of cooperativeness correlated inversely with the level of depression by CES-D test (R = −0.54). Conclusions: With an increase in asthma severity the tendency to hypothymia, correlated with patients' cooperativeness, is revealed, and asthma control achievement is reduced. Background and Aims: We have reported that frequency of lung sounds reflect the degree of airway inflammation in patients with bronchial asthma (BA). (J Allergy Clin Immunol Pract. 2016;4:505) The rumbling rhonchi (RR) denote the rumbling sound which have non sinusoidal wave form in their time-expanded wave form and implying retained secretion in bronchi, thus some aspect of airway inflammation. (Allergol Int. 2012; 61:353 ) The RR are frequently heard in patients with BA when they are rather asymptomatic and are increased when they have even mild asthma symptoms. Thus RR may reflect other aspects of ariway inflammation than what frequency of lung sounds does. We tried to clarify the clinical implication of RR in patients wirh BA. Methods: We studied sixty three adult asthmatics (Age :62.3 AE 15.66, M/F: 36/31, Current smokers; 10) when they had no acute symptoms. After carefully auscultation of the lung sounds, the patients performed pulmonary function tests including FEV1/FVC (%) and FEF75/predicted FEF75 (%). The fractionl exhaled nitric oxide (FENO) was measured as a biomarker of eosinophilic airway inflammation. The RR was devided into three categories; not audible (no), faintly audible (faint) and cleary audible (present). Results: The presence of RR did not reflect presence of airflow limitation as there was no decrease of FEV1/FVC (%) and FEF75/predicted FEF75 (%) when RR were heard. When RR were clearly heard, FENO was tend to be higher than when RR were faintly or not heard (p = 0.10). Background and Aims: It has already been recognized that stress evokes asthma exacerbation; however, the mechanism of how short-term stress gets inside the body is not clear. On the other hand, certain breathing patterns have adverse effects on the airways and lead to symptom exacerbation in asthma. This study aimed to observe the impact of shortterm stress on airway constriction and breathing pattern in patients with controlled asthma. Methods: We recorded respiration and heart rate during resting conditions and a short-term stressor (Stroop test with noise) in women with asthma and healthy controls. Pulmonary function parameters were measured using spirometer before and after stress. Results: The exposure to stress significantly decreased FVC (p < 0.01), FEV1 (p < 0.01) and PEF (p < 0.05) in asthmatic patients, whereas FEV1/FVC level remained unchanged. In contrast to patients with asthma, healthy participants showed significant increases in respiratory rate, respiratory complexity, heart rate variability, and SD1/SD2 (An index of autonomic balance) during stress. The pulmonary function had been inversely correlated with respiratory complexity, heart rate variability, and autonomic impairment. Conclusions: We conclude that autonomic impairment and breathing pattern might be the potential mechanisms of exacerbation in asthmatic people after short-term stress. Background and Aims: Respiratory dynamics exhibits complex pattern of variations. The pathophysiological basis of respiratory pattern decomplexification in asthma is not clear and needs to be determined by studies on animal models of asthma. Also, it is questionable whether asthma-like changes due to repeated bronchoconstriction induced by methacholine (MCh), as a non-allergen agent, can alter the breathing pattern as what expected for asthmatic guinea pig with allergic inflammation. Methods: The respiration of conscious guinea pigs was recorded on day 0 (before saline, Ovalbumin or MCh inhalation) and day 36 (24 h after the 12th aerosol exposure), using a whole-body plethysmography. Twenty minutes of data with minimum artifact was selected for inter-breath intervals analysis using custom written software in MATLAB. Complexity of breathing pattern was quantified by calculating sample entropy that determines the irregularity degree of a time-series. Results: The respiratory dynamics showed an increased regularity in animals challenged with allergen (p = 0.03) or MCh (p = 0.01) compared to Saline group. However, there is no significant difference in respiratory dynamics between asthmatic and MCh groups (p > 0.05). Conclusions: The complexity of breathing pattern is decreased by bronchoconstriction induced by either allergen or MCh in guinea pigs. The airway remodeling due to repeated bronchoconstriction may be the cause of this decomplexification. Background and Aims: Copper oxide nanoparticles (CuONPs), metal oxide nanoparticles were used in multiple applications including wood preservation, antimicrobial textiles, catalysts for carbon monoxide oxidation and heat transfer fluid in machines. We investigated the effects of CuONPs on the respiratory system in Balb/c mice. In addition, to investigate the effects of CuONPs on asthma development, we used a murine model of ovalbumin (OVA)-induced asthma. Methods: In toxicological experiment, mice were received the CuONPs (25, 50 and 100 μg/kg) via intrasal instillation uder slight anesthesia for 3 days. We evaluated airway hyperresponsiveness (AHR), inflammatory cell count, proinflammatory cytokines and reactive oxygen species (ROS) and histopathology. In asthma model, to induce asthma, the mice were senstized on days 0 and 14 with an intraperitoneal injection of OVA. On days 21, 22 and 23, the mice received 20 μg of OVA and CuONPs (25, 50 and 100 μg/kg) dispersed into 50 μL of PBS via intranasal instillation. Results: CuONPs markedly increased airway hyper-responsiveness (AHR), inflammatory cell counts, proinflammatory cytokines and reactive oxygen species (ROS). CuONPs induced airway inflammation and mucus secretion with increases in phosphorylation of the MAPKs (Erk, JNK and p38). In the OVAinduced asthma model, CuONPs aggravated the increased AHR, inflammatory cell count, proinflammatory cytokines, ROS and immunoglobulin E induced by OVA exposure. In addition, CuONPs markedly increased inflammatory cell infiltration into the lung and mucus secretions, and MAPK phosphorylation was elevated compared to OVAinduced asthmatic mice. Conclusions: CuONPs exhibited toxicity on the respiratory system, which was associated with the MAPK phosphorylation. In addition, CuONPs exposure aggravated the development of asthma. We conclude that CuONPs exposure has a potential toxicity in humans with respiratory disease. Background and Aims: Mucus acts as a primary defense system in the airway against various stimuli. However, excess mucus production causes a reduction in lung function via limitation of the airflow in the airway of patients suffering from asthma or chronic obstructive pulmonary disease (COPD). Methods: In this study, we evaluated the effects of melatonin on the production of MUC5AC, a major constituent of the mucin that is secreted from the airway, using epidermal growth factor (EGF)-stimulated NCI-H292 cells, a human mucoepidermoid carcinoma cell line, and an ovalbumin (OVA)-induced asthma murine model. Results: Melatonin treatment significantly reduced the mRNA and protein levels of MUC5AC and reduced interleukin (IL)-6 production in EGFstimulated H292 cells. Melatonin markedly decreased the phosphorylation of MAPKs, including ERK1/2, JNK, and p-38, induced by EGF stimulation. These findings were consistent with the results using MAPK inhibitors. Particularly, co-treatment with melatonin and a MAPK inhibitor more effectively suppressed MAPK phosphorylation than treatment with a MAPK inhibitor alone, which resulted in a reduction in MUC5AC expression. In the asthma murine model, melatonin-treated mice exhibited a marked reduction in MUC5AC expression in the airway compared with the OVAinduced mice. These reductions were accompanied by reductions in proinflammatory cytokine production and inflammatory cell infiltration. Conclusions: These findings indicate that melatonin effectively inhibits MUC5AC expression. These effects may be closely associated with the inhibition of MAPK phosphorylation. Furthermore, our study suggests that melatonin could represent a potential therapeutic for chronic airway diseases, such as asthma and COPD. Methods: A total of 131 cases of asthma who were untreated were retrospectively analyzed in our hospital from 2013 to 2015.Fifty-nine patients were classified to NAA group and Seventy-two to AA group.Allergic asthma(AA) can be objectively distinguished from non-allergic asthma(NAA) by skin prick test and immunoglobulin E (IgE) levels to common allergens. We described differences between allergic and nonallergic asthma such as gender, body mass index ( Gangnam severance hospital, internal medicine, seoul, Republic of Korea, and 2 Goodmorning Hospital, 338-Jungang-ro-Pyeongtaek-si-, Gyeonggi-do, Republic of Korea Background and Aims: Specific immunoglobulin E (IgE) sensitization to staphylococcal enterotoxin (SE) has been recently considered to be related to allergic disease, including asthma. Although some researchers have conducted studies concerning specific IgE (sIgE) to SE and its relationship to asthma diagnosis and severity, association of sIgE to SE with airway hyperresponsiveness (AHR) has not been well studied. Methods: We enrolled 81 asthma patients admitted to the Severance Hospital in Korea from March 1 st , 2013 to February 28 th , 2015 and retrospectively reviewed the electronic medical records of the enrolled subjects. We measured the levels of sIgE to SE (A/B) in serum of all subjects using ImmunoCAP ® 250 (Phadia, Uppsala, Sweden) system. We defined positive to SE-sIgE as more than 0.10 kU/mL. Results: The SE-sIgE level was not significantly correlated with asthma severity (FEV 1 , FEV 1 /FVC, sputum eosinophils, and serum eosinophils), whereas the SE-sIgE level in patients with positive AHR (mean AE Standard error of the mean, 0.606 AE 0.273 kU/mL) was significantly higher than that in patients with negative AHR (0.062 AE 0.015 kU/mL; p-value 0.034). In regression analysis, SE sensitization (sIgE to SE ≥ 0.010 kU/mL) was a significant risk factor for AHR, after adjustment for age, sex, FEV 1 , and sputum eosinophils (odds ratio 7.090; 95% confidence interval, 1.180-42.600; p-value 0.032). Prevalence of SE sensitization was higher in patients with allergic rhinitis and non-atopic asthma patients compared to patients without allergic rhinitis and atopic asthma patients, respectively, but without statistical significance. Conclusions: SE sensitization is significantly associated with AHR. Background and Aims: Difficulties in the achievement of asthma control may be associated with the the shift of the profile of the inflammatory bronchial infiltrate towards polymorphonuclear leucocytes. The aim of the study was to determine the influence of neutrophilic component of the bronchial inflammation on the asthma control, lung function and airway responsiveness. Methods: 114 patients with mild persistent asthma were assessed upon the level of the asthma control by Asthma Control Test (ACT); lung function (FEV 1 ) by spirometry; airway responsiveness (ΔFEV 1 ) to 3-minute isocapnic hyperventilation with cold air (−20 C) (IHCA) and 3-minute ultrasound inhalation with distilled water (IDW). The cell composition of the induced sputum (IS) was also studied. The patients were divided into groups with low contents of neutrophils in IS (39 people; 1 st group) and with high contents of neutrophils (75 people, 2 nd group). Results: The contents of neutrophils in the 1 st group was 10.9 AE 0.53%, eosinophils -19.4 AE 2.1%; in the 2 nd group -29.9 AE 1.6% (p = 0.0001) and 20.4 AE 1.4% (p = 0.66), respectively. By ACT data the people of the 2 nd group managed their disease worse than in 1 st group ( Background and Aims: The influence of standard combination therapy on control of bronchial inflammation in asthma patients with cold airway hyperresponsiveness (CAHR) has not been studied. The aim of the study was to estimate the efficiency of application of the combination therapy in asthma patients with CAHR by the indicators of the pattern of bronchial inflammation. Methods: 12 patients (mean age was 42.4 AE 2.5 years old) with mild persistent asthma and CAHR were studied upon the lung function, asthma control (ACT™), the cell composition of the induced sputum (IS) before and after 48-week therapy with the combination of budesonide/formoterol. The number of inflammatory cells (in %) was studied; mean cytochemical coefficient of myeloperoxidase (MPO) of granulocytes was calculated (in pixels); the intensiveness of cells cytolysis was assessed. The combination budesonide/formoterol in the dose of 640/18 mcg/day was used to achieve control; then it decreased till stable supporting dose of 320/9 mcg/day. Results: Baseline asthma control was 14.4 AE 1.2 points of ACT, FEV 1 -87.4 AE 3.3%. The number of neutrophils (26.4 AE 1.7%) in IS prevailed over eosinophils (18.5 AE 2.6%), the level of MPO was 65.9 AE 5.4 pixels. In 48 weeks of therapy there was a significant improvement of lung function. Asthma control increased till 19.4 AE 1.3 points of ACT (p = 0.0255). In IS there was a significant decrease of eosinophils from 18.5 AE 2.6 till 11.4 AE 3.2% (p = 0.0452); the intensiveness of eosinophils cytolysis decreased from 0.60 AE 0.10 till 0.37 AE 0.04 (p = 0.0459) and of neutrophils from 0.61 AE 0.05 till 0.42 AE 0.04 (p = 0.0457); intracellular concentration of MPO increased from 65.9 AE 5.4 till 98.2 AE 14.1 pixels (p = 0.0637). But the number of neutrophils remained high (34.0 AE 8.2%, p = 0.34), which was considered as the factor of stable initiation of inflammation and oxidative stress. Conclusions: The use of the mode of standard antiinflammatory therapy and long treatment with the combination drug of budesonide/formoterol in asthmatics with CAHR does not help to achieve control over the number of neutrophils in IS. Background and Aims: GINA 2015 stated that tiotropium bromide could be one of the recommended option to add to standard step 4 treatment for asthmatics. Once well-control are maintained with these combination therapy for more than 3 months, theoretically step-down should be started, still the precise strategy for step-down therapy has not been well defined. Methods: Study design is a randomized controlled trial. Severe adult asthmatics, well-controlled receiving GINA treatment step 4 to 5 including medium to high dose of ICS/LABA, LTRA and tiotropium for more than 6 months were recruited. Patients were randomized to maintain their current treatment or discontinue only LTRA (step-down group). FeNO, ACT score, Spirometry and exacerbation rate are examined every 8 weeks for 6 months. Results: 36 patients were enrolled, and step-down was performed in 16 patients. Mean age is 62.2 years old, %FEV 1 is 70.3%, ACT score 21.3 at the time of entry suggesting relatively well asthma control status were enrolled. 4 patients out of 16 dropped out at 4 weeks in 2 cases (PEF #, amount of sputum "), 8 weeks 1 case (exacerbation of asthma) and 12 weeks 1 case (rhinitis symptom ") respectively after discontinuing LTRA. There were no clinical characteristics among dropped-out patients except that they were all female and had received high dose of ICS/LABA combination inhaler. After 6 months, there was no difference between 2 groups in time to first exacerbation (mean number of exacerbations/person-year, 0.42 in step-down group vs 0.37), change in FEV 1 , and ACT score. Conclusions: Withdrawal of LTRA might be safe option when considering the step-down from combination therapy of ICS/LABA, tiotropium bromide and LTRA for severe asthmatics, in case the patients are not received high dose of ICS/LABA. This study was limited by the small sample size and short duration and should therefore be considered preliminary. Background and Aims: To study on the level of fungal-specific Immunoglobulin E (sIgE) and phenomenon of multiple fungal sensitization of the patients who suffer from respiratory disease. Methods: Screen the adult's patients who suffer from asthma and adult allergic bronchopulmonary aspergillosis(ABPA) patients, which its aspergillus fumigates-sIgE was detected as positive and grade should be equal to or greater than level three. It was divided into two groups: Group asthma of aspergillus fumigatus sensitization and Group ABPA. The patient's serum and concentration of IgE's penicillum notatum, Branching cinerea, aspergillus fumigatus, candida albicans mould, alternaria and helminthosporium were detected by ImmunoCAP 1000 fluor euzymelinked immunosorbent system. Results: As a result, group ABPA of patient's aspergillus fumigatus sIgE were significantly higher than group asthma of aspergillus fumigatus sensitization (P < 0.05) [26.7 (13.3,54. 3) kU/L vs. 12.7 (5.9,33.4) kU/L], candida albicans sIgE[7.9 (1.4,6.0)kU/L vs. 1.0(0.4,6.0) kU/L], penicillium notatum sIgE [17.6 (6.8,37.6) kU/L vs. 4.3(4.3,4.3) kU/L], alternaria sIgE [2.6 (1.7,16 .0) kU/L vs. 0.9 (0.4,2.1) kU/L]. All patients embraced the phenomenon of multiple fungal sensitization. There were significant correlation between the sIgE levels of fungus (P < 0.05). Moreover, the optimal scaling technique reflected that the most similar relationship is aspergillus fumigatus and alternaria (Cronbach's Alpha = 95.7%). Conclusions: In a nutshell, the patients who sensitized to aspergillus fumigatus often exist the phenomenon of multiple fungal sensitization. Maybe this phenomenon is caused by the same sensitized protein which secreted by fungus. Combination of different fungus sIgE detection may regard as auxiliary examination of fungal allergic asthma. Background and Aims: Respiratory diseases are refractory disease that remarkably reduces life quality of the patients, and costs a great amount of social wealth. Studies have revealed the correlation between environmental factors and the development and progression of these diseases. We determined particulate matter concentration in the air of bedroom,outdoor and HDM allergen concentrations in the bedding and pillows, before and after applying the HEPA air purifier to evaluate its effect to improve air quality and efficacy for adjuvant therapy of respiratory allergic diseases. Methods: Air purifier was set near the bed in the bedroom for 4 months. 32 people that were 25 AE 14 years old and diagnosed with allergic rhinitis, 11 children,7 adult diagnosed with bronchial asthma were selected. Before application of the purifier and every month after, dust sample was collected with a vacuum cleaner and dust collector, and PM value was measured. The change in PM values was shown in PM ratio. RQLQ and ACT、C-ACT was used to access the symptoms of the patients before and after application of the air purifier. SPSS19.0 was used for data entry and analysis, measurement data was descriptively analyzed, Non-parametric test,independent t test and repeated measurement ANOVA were used to comparison among groups, P < 0.05 was considered statistically significant. Results: Der f1(29.63(29.63,29.63)ng/g) was the most abundant allergen in air of the patient's bedroom, followed by Derp1(78.15(29.63, 82 .41)ng/ g)Der f1 concentration(416.50(342.64,651.52)ng/g)in bedding and pillows was higher than Der p1 (153.55(34.39,618.84)ng/g. Der f1 and Der p1 concentration slightly decreased after application of the air purifier. PM1.0, PM2.5, PM10 concentration significantly decreased in the first three months, but increased in the 4 th month. Score for activity limitation practical problems declined all the way. Conclusions: Air purifier, when properly functioning, can effectively reduce PM and HDM allergen concentrations in the air, and thereby improve clinical manifestations of patients with allergic rhinitis and asthma. Background and Aims: Reported prevalence of bacterial and viral infection in acute exacerbation of asthma vary by regions, and most reported study have been conducted in western countries. And recent guidelines for management of asthma recommend that antibiotics should not be routinely prescribed for acute exacerbation of asthma. So, we investigated the prevalence of bacterial and viral infection and the predictable markers for bacterial infection in acute exacerbation of asthma in single center in South Korea. Methods: We retrospectively analyzed the medical records of patients with acute exacerbation of asthma admitted to the Korea University Guro Hospital from January 2011 to June 2015. We searched our electronic medical records database with key words "Asthma", "Acute exacerbation". Results: There were 121 episodes of acute exacerbation in 101 patients. There were 38 men and 63 women, and mean age was 64.3 AE 15.2 years. The numbers of patients with bacterial infections, viral infections, both bacterial and viral infections, and no pathogen were 19 (15.7%), 32 (26.5%), 22 (18.2%), 48 (39.7%), respectively. The major bacteria were Streptococcus pneumonia (15.7%), Haemophilus influenza (7.4%), and the major viruses were rhinovirus (14.05%), influenza virus (11.57%). Serum eosinophil counts was significantly lower in the bacterial positive group (P = 0.002) and serum C-reactive protein (CRP) and procalcitonin (PCT) level were higher in the bacterial positive group (P = 0.001, P = 0.010, respectively). Conclusions: This study showed that Streptococcus pneumoniae and rhinovirus were the most common isolates in acute exacerbation of asthma. Serum eosinophil counts and serum CRP and PCT levels can be used to distinguish bacterial infection in acute exacerbation of asthma. These findings provide useful information for antibiotic treatment in patients with acute exacerbation of asthma. Background and Aims: Asthma is characterized as airway hyperresponsiveness and airflow obstruction at the bronchial level. It is often reversible, either spontaneously or with treatment. In the last decades, a continuous increase in the prevalence of asthma has been observed worldwide. The complexity of this chronic disease is particularly challenging, and more research is needed on the environmental determinants of the disease because the increase in asthma incidence over the last decades strongly suggests a role of environmental and air pollution. The street sweepers are exposed to dust particles, bioaerosols and various harmful gases. Inhalation of these particulates enter the lungs and may leading to adverse respiratory ill effects. In fact that the street sweepers usually would not use protective devices like face masks and exposure to the dust generated during sweeping may have contributed to increase in the prevalence of lung disease. This is a preliminary (cross sectional) study of prevalence asthma among street sweepers in Jakarta, Indonesia and have been approved by ethical committee faculty of medicine Universitas Indonesia. Methods: This research design is cross sectional with the subjects are street sweepers in Jakarta Indonesia. Sample collection using a cluster random sampling through questionnaire of Asthma Screening Questionnaire (ASQ) and Asthma Control Test (ACT), spirometry examination based on Pneumobile Project Indonesia and bronchodilator test. The inclusion criteria are male and female, able to perform spirometry, signed an inform consent, 15-60 years old and work period more than 2 years. Results: Thirty street sweepers whose work in the same area participated in this study, most age 18 to 60 years old that is 6 female (20%) and 24 male (80%). Prevalence of asthma among street sweepers in the same area is 3.3%, this subject is 20 years old female. Conclusions: Prevalence of asthma among street sweepers in Jakarta, 2016 is 3.3%. Background and Aims: Measuring peak expiratory flow (PEF) is an easy and inexpensive method for monitoring of bronchial asthma. Many digital peak flow meter (PFM) or smart phone apps have been developed. However, the clinical applications are limited in Korea. We have been developing the portable digital PFM with asthma monitoring system software for android mobile devices. One part of this project was development of portable digital PFM, and we made a prototype of digital PFM. The aims of this study were to compare its performance with that of the miniature Wright PFM, and to share the experience of process of our project. Methods: The prototype of digital PFM have been compared with the min-Wright PFM by a pair of calibrators. The same flow were provided by two calibrators simultaneously. The data of digital PFM were transmitted to the app of smart phone by Bluetooth and the PEF values were shown on the screen of smart device. The PEF values of the mini-Wright PFM were read on the analogue scale directly. Results: 50 pairs of PEF values were obtained. Values of PEF were between 100 L/min and 600 L/min. Strong positive correlation was shown between the PEF of both digital PFM and mini-Wright PFM (p < 0.001) (Fig.1) . The digital PFM could be used clinically. And it would be used for a part of asthma monitoring and alarming system in patients with asthma. Background and Aims: Asthma is a common respiratory illness, affecting almost 2.05% Indians. It involves airway inflammation and hyper responsiveness. A significant percentage of asthmatics show the presence of atopy to various allergens, including food allergens. In the present study we looked for the pattern of food sensitization in asthmatics in India. Methods: A total of 203 asthmatic patients (diagnosed according to GINA guidelines) were enrolled. These patients underwent skin prick testing against food allergens. A total of 67 allergens commonly consumed were tested against. Results: Food sensitization was present in 46% of asthmatic patients. The most common group causing sensitization was animal products (5.9%), followed by Legumes (3.7%) and seeds and cereal grains (1.9%). Individually, the five most common foods were Prawn (16.3%), Fennel (7.9%), Red gram (7.4%), Baker's yeast (6.9%), and Beans (5.4%). Conclusions: Among Indian patients suffering from asthma we found animal products to be the most common offending agents, followed by legumes. Individually, prawns, fennel, red gram, baker's yeast and beans were five commonest sensitizing foods. We further found out which out of the 67 food allergens were the commonest sensitizing agents in asthmatics in India. Background and Aims: Previous studies have demonstrated that the mutant GLCCI1 rs37973 genotype is associated with poor inhaled corticosteroid (ICS) response in asthmatics. As human airway relaxation is regulated by circulation epinephrine (EPI), which can be enhanced by corticosteroid. It is unknown whether or not the mutant GLCCI1 rs37973 is associated with circulation concentration changes of epinephrine and cortisol in asthma, so the aim of this study is to evaluate these relationships. Methods: A total of 182 asthmatics and 180 healthy controls were recruited for the study. 30 mild-to-moderate asthmatics received fluticasone propionate (125 μg, bid) treatment for 12 weeks. GLCCI1 rs37973 genotyping was performed with the iPlex MassARRAY genotyping platform. The plasma concentrations of cortisol (COR) and epinephrine of each participant were detected by ELISA kits. Results: GLCCI1 rs37973 homozygotes mutant genotype GG had a higher plasma epinephrine concentration (median concentration 27.032 pg/ml, n GG =36; median concentration 23.149 pg/ml, n AA+AG =146; P = 0.015) and cortisol concentration (median concentration 1.141 ng/ml, n GG =36; median concentration 0.921 ng/ml, n AA+AG =146; P = 0.013). Both epinephrine concentration and cortisol concentration in plasma were positively correlated with FEV 1 (r = 0.889 and r = 0.821, respectively), but not correlated with GLCCI1 mRNA expression. For asthmatics treated with ICS, rs37973 was associated with plasma epinephrine and cortisol concentration change in a recessive model (AA + AG vs GG), with GG had less improvement in epinephrine concentration [5EPI AA+AG = 6.843(9.26) pg/ml, n AA+AG = 26; 5EPI GG = −1.666(6.52) pg/ml, n GG = 4; P = 0.018] and cortisol concentration [5COR AA+AG = 0.3040(0.21) ng/ml, n AA+AG = 26; 5COR GG = −0.066(0.24) ng/ml, n GG = 4; P = 0.009]. Conclusions: Our study suggested that the poor ICS response in GLCCI1 rs37973 mutant genotype might be related to the less increase amplitudes of plasma epinephrine and cortisol in asthmatic patients. Background and Aims: Against a background of long term respiratory limitations when living with asthma, stigma has also been identified as a social phenomenon among adult asthmatics. The main objective of this study was to validate the newly devised Malay version of Stigma Scale (M-SS) for use in a group of Malaysian patients diagnosed with asthma. Methods: In this cross-sectional study, 152 adult asthma patients were enrolled from four respiratory clinics located in Selangor, Malaysia. The permission to adapt and translate the questionnaire was obtained from the corresponding author. The questionnaire was translated into Malay language by forward and backward translation, harmonization, cognitive debriefing interviews and proof reading. After establishing the content and face validity, the extracted data from completed questionnaires were analysed for construct validation. Moreover, reliability was assessed by Cronbach's α and intraclass correlation coefficient (ICC) for internal consistency and one month test-retest reliability, respectively. Results: The final 22-item M-SS was found to be a reliable instrument using a measure of internal consistency (Cronbach'α = 0.821) and one month test-retest reliability (ICC = 0.894). Moreover, Kaiser-Meyer-Olkin (KMO) measure verified the sampling adequacy (KMO = 0.707) and Barlett's test of sphericity (x 2 (231) = 1836.20, p < 0.001) indicated that correlations between items were sufficiently large enough for factor analysis. The analysis of scree plot and eigenvalues suggested to retain three factors that were named as discrimination, disclosure and perceived positive on the basis of nature of items. Conclusions: M-SS was found to be highly reliable and valid instrument to assess the stigma in Malaysian adult asthma patients. As questionnaire development is an iterative process, so this study suggests to test this instrument in other Malaysian states for further reinforcement of good psychometric properties. Background and Aims: Asthma is a significant health problem. Twothirds of asthmatic patients are sensitized to common allergens. Sensitization to fungus particularly Aspergillus is associated with increased risk of severity and development of ABPA. Sensitization to the tune of 52% is reported from North of India. Scant data is available from South. This study was done to assess the occurrence and factors associated with Aspergillus sensitization in Bangalore Results: Sixty one patients were studied; mean age was 41.6 AE 16 years, M:F = 0.7:1. Of the 61 patients, 23(37.7%) and 38(62.2%) were from urban and rural areas respectively. Eight (13.11%) patients had history of atopy, 36(59.0%) had allergic rhinitis and 6 (9.83%) had family history of asthma. Eleven (18.03%) patients were smokers. Cutaneous sensitization to Aspergillus fumigatus was seen in 21(34.4%) patients. There was no correlation between Aspergillus sensitization and duration of illness, presence of allergic rhinitis, history of atopy, smoking status, or area of residence (rural vs urban). No association of Aspergillus sensitization with asthma severity or its control. Conclusions: Aspergillus sensitzation was seen in 34.4% of asthmatics in this cohort. There was no association of Aspergillus sensitization with demographic and clinical factors, asthma severity or its control. Background and Aims: Oxidative stress plays an important role in maintaining the inflammation of respiratory tract and loss of asthma control. Aim of the study was to evaluate two-day dynamics of the indexes of lipid peroxidaion in the blood of asthma patients after single exposure to hyposmolar stimulus. Methods: 32 patients (mean age 41.7 AE 1.4 years; FEV 1 94.6 AE 3.2%) with mild persistent partly controlled or uncontrolled asthma (Asthma Control Test -18.2 AE 0.8 points) were involved in the study. FEV 1 was measured by spirometry, and the content of lipid hydroperoxides, vitamin E and ceruloplasmin in blood serum was measured by colorimetric methods. All measurements were taken before and after 3-minute inhalation of distilled water (IDW), and on the next day. Statistical significance of differences were determined using Mann-Whitney paired test. Results: FEV 1 did not differ in the first and second days of the study (2.92 AE 0.12 and 2.89 AE 0.11 L, respectively, p = 0.32). Mean ΔFEV 1 in response to IDW consisted of −5.8 AE 1.9%. The average content of lipid hydroperoxides in the first day of study consisted of 9.39 AE 0.44 nmol/ml and slightly increased to 10.44 AE 0.42 nmol/ml (p = 0.0498) in response to IDW. On the second day the lipid hydroperoxide content increased 1.5fold to 15.11 AE 0.53 nmol/ml (p = 0.0001) and correlated with baseline FEV 1 (r = −0.36, p = 0.044). Vitamin E content in the first day significantly increased from 28.9 AE 1.55 to 33.5 AE 1.84 mg/ml (p = 0.009) after IDW, and the next day consisted of 30.1 AE 1.09 g/ml (p = 0.50). The content of ceruloplasmin in the blood serum significantly increased from 20.5 AE 0.93 in the first day to 23.7 AE 1.39 mg/100 ml on the second day (p = 0.012). The change of ceruloplasmin just after IDW was statistically insignificant. Conclusions: In patients with asthma a single inhalation of distilled water is followed by the development of oxidative stress, which symptoms persists for at least a day. This work was supported by the Russian Science Foundation (grant №14-25-00019). Results: Most patients with COPD were males >60 years, 75% had severe disease (GOLD III). 80% were smokers, 65% had exposure to indoor air pollution due to use of biomass fuels, 10% had history of TB & 20% had alcohol abuse. Patients with bronchial asthma were young females <40 years, 45% had mild asthma. 10 % of the patients in each category had overlap of COPD and asthma. They had severe symptoms, consumed alcohol regularly & had significant exposure to indoor air pollution. Conclusion: Tobacco smoking, toxic exposure to indoor smoke, towering burden of TB and alcohol abuse are the risk factors that converge together at the interface between COPD & Asthma in Low Income Country. There is a need to reconstruct the prevailing paradigm of lung health in low-income countries like Nepal on the basis of these available evidences. Background and Aims: Historically, dry powder inhalers (DPIs) were considered to provide better airway distribution, easier identification of empty devices, and easier handling when compared to pressurized metered dose inhalers (pMDIs). Prior research into the major handling errors with inhaler device use has shown that errors result in comparable impairment of asthma control in both DPIs and pMDIs. Our own research has demonstrated that patients who are prescribed similar types of preventer inhaler devices to their reliever have better asthma control. Patients prescribed pMDI inhaled corticosteroid/long acting beta agonist relievers could benefit from switching from a DPI to a pMDI. The Health Insurance Review and Assessment (HIRA) database provides coverage of medical claims for over 50 million people in Korea and offers the opportunity to study asthma control on a national basis. The aim of this study was to provide a review of the possibilities of the Korean HIRA database in preparation for a study to investigate the effect on asthma control when patients switch inhaler types. Methods: Methodology from previous literature describing the HIRA database was analysed. We focused on the identification of asthma patients, their clinical characteristics (e.g. exacerbations, comorbidities), real-life medication switching behaviour, healthcare resource use (including medication) and associated costs. Results: Patient medical history could be constructed from primary and secondary diagnosis associated with individual database entries. Asthma exacerbations could be proxied by a prescription of acute oral corticosteroids, hospital admission or emergency room attendance associated with a diagnosis of asthma, lower respiratory infection or respiratory failure. Patients could be considered switch patients if they received a prescription of a pMDI after prescription of ≥2 DPI inhalers. Additional variables that were available included medication and hospitalisation cost. Conclusions: The HIRA database will allow studies analysing switch success of inhaler types in terms of persistence, asthma control and healthcare resource utilisation. Background and Aims: Case Presentation: A 41/female with ovarian cancer had sudden dyspnea. 2d-echo showed dilated right ventricle and atrium, signs of pressure and volume overload, severe pulmonary hypertension (PH) and patent ductus arteriosus (PDA). She was advised PDA closure but not done. She again presented at the ER with a BP of 70/40. Chest CT-angiography now showed large bilateral main pulmonary artery emboli and PDA, and hypoxemia with high Alveolar-arterial gradient on blood gas. There were no thrombosis on leg duplex scan and abdominopelvic CT-angiography. Low-molecular weight heparin (LMWH) was then started as treatment which resulted in improvement of her BP and dyspnea. However, repeat chest CT angiography 1 month after LMWH revealed persistence of the emboli and 2d-echo still showed severe PH. Pulmonary endarterectomy was planned for chronic thromboembolic pulmonary hypertension, but was not done. Right heart catheterization showed significant step-up at the level of the right ventricle to the main pulmonary artery, with a predominant left to right shunt (Qp/Qs: 1.16:1), confirming a PDA. Unfortunately, there is irreversibility of the PH, making her not a good candidate for PDA closure and high risk with endarterectomy. CA-125 was markedly elevated, which suggests ovarian cancer. The severity of PH precluded any invasive procedure and an abdominal pigtail was inserted as palliative care. Our case is indeed very unfortunate, since she might already have elevated PA pressures from the PDA, and was further aggravated by the PTE (presumably from the underlying malignancy), the combination of the three diseases significantly worsens her prognosis. Closure of the lesion before the onset of irreversible PH is treatment for PDA, while surgical removal of emboli constitute management for persistent PTE. However, irreversibility of PH documented during right heart catheterization coupled with the high risk nature of her disease precluded any invasive procedure to be done, resorting to palliative measures. Background and Aims: There are no data about bronchial leukocytes activation by cytokines in asthmatics with osmotic AHR. The aim of the study was to assess the activity of MPO and cytolysis of bronchial leukocytes in hyperosmolar AHR depending on the IL-8, IL-5. Methods: 11 asthma patients (1st group) with airway hyperresponsiveness to inhalation of ultrasound nebulized hypertonic (4,5% NaCl) solution (IHS) and 19 patients without response (2nd group) were examined. 12 healthy persons were in the control group. In leukocytes of induced sputum mean cytochemical coefficient (MCC, in pixels) of MPO and intensiveness of cells cytolysis (ICC, in a.u.) were determined. The concentrations of IL-8, IL-5 (pg/mL) in exhaled breath condensate were measured by ELISA. Results: ICC of neutrophils in the 1st group was 0.44 AE 0.02 a.u., in the 2nd group -0.31 AE 0.02 a.u. (p < 0.001), in the control group -0.11 AE 0.007 a.u. (p < 0.001). ICC of eosinophils was 0.34 AE 0.03, 0.32 AE 0.02 and 0.08 AE 0.006 a.u. (p < 0.001), respectively. Activation of neutrophilic cytolysis in the 1st group was associated with increased activity of MPO: MCC was 158. Background and Aims: Corticosteroids (CS) are widely used for various inflammatory diseases including bronchial asthma. The efficacy and adverse effects of CS are heterogeneous in individual patients, which may be partly caused by genetic variations in inflammatory cytokines and transcription factors which CS acts on. A single nucleotide polymorphism (SNP) rs37972 of glucocorticoid-induced transcript 1 (GLCCL1) was reported to be associated with clinical effects of inhaled corticosteroid in asthma. The present study was intended to analyze the relationship between GLCCL1 gene polymorphism and the inhibitory effects on cytokine production by methylprednisolone (mPSL). Methods: Peripheral blood mononuclear cells were purified from 54 healthy volunteers and incubated in culture plates coated with anti-CD3 antibody in the presence of anti-CD28 antibody for 24 hr. Various concentrations of mPSL were add to cultures. Concentrations of cytokines (IL-b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, TNF-a, TNF-b, INF-g) in culture supernatants were measured by the bead method using a flow cytometer. We genotyped rs37972 by the TaqMan probe and analyzed the relationship between the gene polymorphism and the 50% inhibitory concentration (IC50) of mPSL for individual cytokines. Results: Genotype frequencies of rs37972 were 37% for GG (n = 20), 44% for G/A (24) and 19% (10) for AA, and similar to those of 934 healthy Japanese uploaded on the NBDC of Japan site. Rs37972 was significantly associated only with IC50 of mPSL for IL-5 production; however, the allele for weak response (high IC50) was G and inconsistent with one previously published. Conclusions: Given the lack of strong and consistent association between rs37972 and inhibitory effects of mPSL in vitro, further studies are needed to establish the clinical significant of this SNP. Background and Aims: Prostaglandin E 2 (PGE 2 ) is a major eicosanoid with multiple and often opposite effects in the human body. Its protective effect on the respiratory system under some conditions including bronchoconstriction induced by ultrasonically nebulized distilled water (UNDW) has been known for a long time. In the course of our research of eicosanoids involvement in osmotic airway hyperresponsiveness (OAH), the aim of this study was estimation of PGE 2 in exhaled breath condensate (EBC) and serum in asthmatics with different responses to hypo-and hyperosmolar stimuli. Methods: EBC was collected from 20 asthmatics before and after 3-min provocation with UNDW. Serum was collected from 60 patients before any provocation (UNDW or ultrasonically nebulized hypertonic solution (UNHRS, 4.5% NaCl). Content of PGE 2 was measured in EBC after freeze-drying and in serum without preliminary purification by an EIA commercial kit (R&D systems, USA). Results: PGE 2 was detected in EBC of only 7 patients: 5 samples before and 4 after UNDW. Among them, only 2 patients were found to have PGE 2 in EBC both before and after the provocation. 4 patients with detected PGE 2 in EBC belonged to the group with hyperresponsiveness to UNDW (PGE 2 = 11.8-61.1 pg/mL) and 3 were without it (PGE 2 = 6.1-83.9 pg/mL). PGE 2 content in serum was in the range of 55.1-1875.2 pg/mL. There were no statistical differences between the groups of asthmatics with different airway responses to osmotic stimuli (UNDW or UNHRS). However, we found significant correlations between PGE 2 content in serum and some lung function indices for the patients with OAH to UNHRS. Conclusions: The content of PGE 2 in EBC is very low to be involved in OAH at least to UNDW. PGE 2 content in serum is associated with lung functions of asthmatics with OAH to hypertonic solution. The research was supported by Russian Scientific Foundation (grant No.14-25-00019). (+)DVT-father 5 days before admission, patient developed cough, hemoptysis and bilateral pleuritic chest pain. Consult at ER yielded normal chest x-ray and he was sent home. 5 days after, consulted the outpatient department for persistence of symptoms, plain chest CT scan revealed lower lobe nonhomogeneous opacity on the left basal area, and a smaller one on the right. Cavitary PTB vs pneumonia was considered and he was admitted and given Moxifloxacin 400mg once daily. Sputum AFB and TB gene expert were negative. Patient complained of progressive symptoms despite antibiotics on 2 nd hospital day, chest x-ray now showed left-sided pleural effusion and atelectasis. 43cc fluid on the left seen on ultrasound. Antibiotic shifted to Piperacillin-Tazobactam. Bronchoscopy on the 3 rd day showed blood clots on the left basal segment. Bronchial washings (TB gene expert, cultures including legionella, mycoplasma, PCP) and autoimmune/HIV tests were all negative. Patient underwent chest CT angiogram on 4 th hospital day, showed filling defects representing thrombus, impression was pulmonary thromboembolism, both lower lungs, with complete occlusion of left basal trunk and branches. Low molecular weight heparin (LMWH) was started every 12 hours. 2D-Echo and venous duplex scan of lower extremities were unremarkable. On the 6 th hospital day, less hemoptysis, but developed fever, TMAX of 38.2 C, total of 3 episodes. On his 9 th hospital day, patient claims to feel a lot better but complains of vague pain on left upper inner arm. Venous duplex scan of upper extremities revealed heterogenous hypoechoic intraluminal density, representing acute-subacute superficial vein thrombosis partially occluding the left cephalic and basilica veins. LMWH was shifted to Rivaroxiban 15mg BID and patient was sent home. Results: Eighty-nine surgeries were performed in 84 patients. Mean pulmonary embolism severity index (PESI) was 85.9 AE 28.4 (class I (18.0%), class 2 (39.3%), class 3 (23.6%), class 4 (11.2%), class 5 (7.9%). Patients received anticoagulation therapy using heparin (27 cases, 30.3%), and low molecular weight heparin (24 cases, 27.0%). However, no anticoagulation therapy was prescribed in 30 cases of PTE (33.7%). The mean period between the surgeries and the diagnosis of PTE was 14.8 AE 21.6 days. Mean anesthesia time was 220 AE 139 minutes. After surgery, 31 patients admitted ICU for close observation. Although almost no immediate postoperative complication was identified, recurrent PTE was confirmed in 1 patient on the next day of surgery, who discharged alive 50 days after surgery. Two patients died of uncontrolled infection and 1 patient of cardiac tamponade within 90 days. All causes of death were unrelated to PTE. Conclusions: Orthopedic surgery within 3 months in patients with acute PTE can be feasible. Background and Aims: The pathological features of high-altitude pulmonary edema (HAPE) were characterized by marked diffused alveolar edema, alveolar hyaline membranes, dilatation of pulmonary capillaries, pulmonary arterial thrombosis and secondary bronchopneumonia, but with maintained alveolar structure under light microscope. Up to date, the rapid collection of fluid in the lung of HAPE is not yet sufficiently explained by the contemporarily demonstrated mechanisms of resultant pulmonary hypertension, misdistribution of perfusion, and increased pulmonary capillary permeability. Methods: In order to refresh the pathogenesis of HAPE regarding the pulmonary capillary permeability, we report our novel findings about ultrastructure of pulmonary alveolar-capillary wall in two cases with HAPE observed by electron microscope. Results: We found that the neutrophils were trapped in the pulmonary capillaries and that a part of neutrophil was protruded in adherence to the basement membrane of capillary endothelium with activation and degranulation of the neutrophil. The wall of endothelial cell in the pulmonary capillary was deformed and thick with swellings and degeneration. In side of alveolar space, the infiltrations of neutrophils and macrophages and the proliferation of type II pneumocytes were also observed. The electron microscopic observation confidently provided evidence that the structure of pulmonary alveolar-capillary wall was impaired with deformation and thickness probably due to adherence to neutrophil that is activated and de-granulated by stimulus of hypoxia. Such structure injury might be the fundamental precondition for the solute and fluid penetrating speedily from capillary side into alveolar side, eventually fluid collection in the alveolar spaces occurring HAPE. Background and Aims: Allergic Rhinitis(AR) impairs the patients' quality of life and brings heavy economicburden on society. Growing evidences suggest that air poluution is correlated with occurrence of allergy symptoms. Air pollutants, mostly suspended factors including PM2.5, ozone and nitrogen oxides may facilitate allergens assessing the immunoregulatory cells and promote development of allergic symptoms. However, whether PM2.5 level is directly correlated with symptoms of AR patients is unclear, if it is, then would it be possible to improve the quality life of these AR patients by reducing PM2.5 level? This study aims to improve the correlation between quality of life of AR patients and PM2.5 level in their surrounding enviroment, and to evaluate the efficacy of air purifier to improve quality of life of AR patients. Methods: 52 clinicaly confirmed AR patients were enrolled in this study, including 30 males and 22 femalesss, aging 20 + 6.5 years. The subjects were asked to fill in a Rhinitis Quality of Life Questionnaire(RQLQ) evryday for a month and corresponding PM2.5 levels in their living enviroment were recorded. Simultaneously,the patients were asked to fill in the RQLQ every month to monitor symptoms of the AR patients before and after using an air purifier. Data collection considered statiscally significant. Results: Among the sub scores of RQLQ, nasal symptoms 5(2,8)(r s = 0.121,P < 0.001) and PM2.5 correlation (31(24,40)g/m3)showed significant correlation (p = 0.048);while daily activity (3(1,8) )(r s = 0.146,P < 0.001),sleeping quality (2(0,3))(r s = 0.059,P = 0.051),non-nasal symptoms (5(1,7))(r s = 0.042,P = 0.169),emotional problem (1(0,4))(r s = 0.042, P = 0.168) were not significantly correlated with PM2.5 level. Conclusions: PM2.5 level is correlated with nasal symptoms of AR patients; air purfier can effectively lower PM2.5 level,alleviate certain symptoms of the AR patients and improve their quality of life. Background and Aims: Bilateral giant pulmonary artery aneurysms are rare pathologic entity in thoracic cavity. Deterling and clagett reported only eight cases from 109,571 post mortem examination. We present the case of 21 year old filipina, previously diagnosed atrial septal defect, now with incidental findings of bilateral pulmonary artery aneurysm (6.2cm and 4.3cm) and aneurysmally dilated main pulmonary artery (5.9cm). Peripheral wall filling defects were also noted in both right and left pulmonary artery. Intensive medical treatment was proposed to this patient with clinical improvement of signs and symptoms. Methods: Bilateral giant pulmonary artery aneurysms (PAA) are rare pathologic entity in thoracic cavity. There is no specific report regarding the prevalence of PAA. It is define as dilatation of pulmonary artery. Barbour mentioned a cutoff of 4cm diameter for pulmonary artery. PAA would present a very nonspecific symptoms like dyspnea, chest heaviness and pain. Other would present as hemoptysis. In this case report, I would present a case of 21 year old Filipina with incidental finding of giant PAA. Results: CT angiogram of the pulmonary arteries revealed aneurysmally dilated main pulmonary artery, right and left pulmonary arteries with peripheral wall filling defects seen at right and left pulmonary arteries down to interlobar arteries which might represent chronic thrombus formation. Conclusions: PAA is a rare diagnosis. Bilateral giant pulmonary artery aneurysms are rare pathologic entity in thoracic cavity. Deterling and clagett reported only eight cases from 109,571 post mortem examination. There are several surgical technique that can be offer in our patient. However, due to the presence of probable eisenmengerisation, the only definite treatment in our patient is to do a cardiac and lung transplantation. However, our patient and her relatives refused to undergo any surgical procedure. Hence, we arranged a regular close follow-up visit for her. She was discharged stable and improved. Background and Aims: This study was conducted to evaluate the association between AR and mental health status in the general Korean adult population and to investigate the relative burden of AR on mental health using the Allergic Rhinitis and Its Impact on Asthma (ARIA) classification Methods: Survey 2011-2012. Univariate analysis was conducted in the healthy AR groups with weighted prevalence of demographic characteristics, socioeconomic status, and comorbid diseases. Subanalysis that classified AR severity according to the ARIA classification was carried out to evaluate the relationship of AR severity with mental health. The odds ratios (ORs) for each component representing mental health status were estimated by multiple logistic regression analysis with confounder adjustment. Results: Univariate analysis with the chi-square test after adjustment for age, sex, body mass index, smoking status, alcohol use status, and exercise status, components representing mental health status showed a linear relationship with the severity of AR according to the ARIA classification. Stress, depressive mood, suicidal thoughts, and psychological consultation factors were correlated with AR after adjustment for demographic characteristics and socioeconomic status. Even after adjustment for comorbid allergic diseases, the correlation remained significant with stress, depressive mood, and psychological consultation factors ( Conclusions: Patients with AR appear to be at higher risk of mental disorders in the general Korean adult population. Moreover, persistent or severe AR was correlated with poor mental health. Therefore, better control of AR may be conducive to better mental health, and more attention should be paid to the psychological status of AR patients. Background and Aims: Introduction: Mycotic pulmonary pseudoaneurysm is an uncommon complication of cavitatory pneumonia, associated with organisms like mycobacterium tuberculosis, staphylococcus aureus, mucormycosis (Vaishali et al), and carries a high mortality risk. We report an interesting case of severe pneumonia with a mycotic pulmonary pseudoaneurysm that failed bronchial artery embolization therapy. Methods: Case presentation: A 77 year old Indian Male, smoker of 50 pack years, with previous history of stroke, hypertension and peripheral vascular disease presented with sudden onset of hemoptysis, and reported coughing out 300 milliliters of fresh blood prior to hospitalization. He denied chest pain, fever, night sweats, weight loss, prior pulmonary tuberculosis, or recurrent chest infections. Clinical examination revealed tachypnea and coarse crepitations in the right lung base. He deteriorated with worsening type 1 respiratory failure, was intubated and stabilised in the ICU. CT Thorax (Fig 1&2) revealed bilateral lower lobe consolidation with cavitations in the right lower lobe with a mycotic pseudoaneurysm along the posteromedial wall of a cystic lesion. Results: Antibiotic therapy was initiated, his blood and sputum was negative for organisms on culture and smears for pulmonary tuberculosis were negative. He underwent successful bronchial artery embolization, blood product transfusions and was closely followed up. Massive hemoptysis recurred and a repeat CT showed no obvious focus of active bleed. Decision was made for surgical intervention and hence he underwent right lower lobectomy. A right lower lobe pseudoaneurysm invading the right diaphragm was noted intra-operatively. The histology of the resected lung was negative for malignancy. Thereafter he made progressive recovery, was discharged and is doing well. Conclusions: Mycotic pseudoaneurysm presenting with hemoptysis requires emergent management with multidisciplinary approach. Bronchial artery embolization has been the preferred initial treatment for hemostasis. This case illustrates the need for vigilant follow up even after success at embolization and prompts early decision for surgery when embolization fails. Background and Aims: Femoral head avascular necrosis was a common disorder among lupus patients. It caused a lot of negative effects on quality of patients' life. The aim was to explore the clinical and paraclinical characteristics of femoral head avascular necrosis among systemic lupus erythematous patients. Methods: A cross sectional study was carried out with 32 systemic lupus erythematous patients who also had femoral head avascular necrosis. The study was conducted at Center of Allergy and Clinical Immunology, Bachmai hospital from 2013 to 2015. All patients fulfilled the SLICC 2012 criteria for the classification of SLE. Patients with femoral head avascular necrosis were symptomatic and had the diagnosis of femoral head avascular necrosis made from plain radiography, bone scan, and/or MRI scan. Results: The mean age at the time of study was 35 years (range 19-67). The highest age group was 21-40 years old, 40,6%. There was 17 patients (53,8%) who had femoral head avascular necrosis IV on X-ray or MRI. Renal disorder was the most common seen, 43,7%. Painful symptoms correlated with the level of necrosis femoral head. Dyslipidemia and low bone density were risk factors of femoral head avascular necrosis. Conclusions: More than a half of SLE patients had severe femoral head avascular necrosis (level IV), among of them, nearly 50% had renal disorder. Femoral head avascular necrosis was more common among young patients and late recognized. Background and Aims: Respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD), and lung infections have critical consequences on mortality and morbidity in humans. The aims of the present study were to examine the mechanisms by which CXCL12 affects MUC1 transcription and airway inflammation, which depend on activator of G-protein signaling (AGS) 3 and to identify specific molecules that suppress CXCL12-induced airway inflammation by acting on G-proteincoupled receptors. Methods: We charried out Western Blotting anlaysis to detect the specific gene expression and used mouse lungs. Results: Herein, AGS3 suppresses CXCL12-mediated upregulation of MUC1 and TNFα by regulating Gα i . We found that the G-protein regulatory (GPR) motif peptide in AGS3 binds to Gα i and downregulates MUC1 expression; in contrast, this motif upregulates TNFα expression. Mutated GPR Q34A peptide increased the expression of MUC1 and TGFβ but decreased the expression of TNFα and IL-6. Moreover, CXCR4-induced dendritic extensions in 2D and 3D matrix cultures were inhibited by the GPR Q34A peptide compared with a wild-type GPR peptide. The GPR Q34A peptide also inhibited CXCL12-induced morphological changes and inflammatory cell infiltration in the mouse lung, and production of inflammatory cytokines in bronchoalveolar lavage (BAL) fluid and the lungs. Conclusions: Our data indicate that the GPR motif of AGS3 is critical for regulating MUC1/Muc1 expression and cytokine production in the inflammatory microenvironment. W. HIROFUMI Yokosuka City Hospital, Internal medicine, Yokosuka, Japan We report the case of a 25-year-old female who has asymptomatic isolated unilateral absence of a proximal pulmonary main artery (UAPA). She was referred to our hospital with the abnormality showing on her chest X-ray at 15 years of age. The diagnosis was confirmed by pulmonary angiography, which showed absence of the right pulmonary artery and collateral circulation to the ipsilateral lung. There was no evidence of pulmonary hypertension upon cardiac catheter examination. She safely delivered twice with careful management using the Swan-Ganz catheter and has remained asymptomatic and healthy without any medication. UAPA is a rare congenital lesion but should be kept in mind as a differential diagnosis in patients with abnormal chest X-rays. UAPA may cause a variety of symptoms. Although some patients with isolated UAPA are completely asymptomatic, others may have severe pulmonary hypertension and congestive heart failure. We report this case and consider the mechanism of its symptomatic variation in a literature review. Background and Aims: Repeatedly hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are often exposed to more antibiotics, but the distribution of pathogenic bacteria in these patients is poorly understood. The objectives of this study were to analyze the distribution of pathogenic bacteria and the risk factors associated with multidrug-resistant (MDR) bacteria infection in early readmission patients with AECOPD. Methods: We retrospectively reviewed charts for patients with AECOPD admitted to our hospital between January 2011 and November 2012. The early readmission group and non-early readmission group were determined by whether patients were readmitted within 31 days after discharge. Detection of potentially pathogenic microorganisms (PPMs) and MDR bacteria were analyzed. Logistic regression analysis was performed to identify independent risk factors for MDR bacteria infection. Background and Aims: Cycle ergometer training (CET) has been shown to improve exercise performance of quadriceps muscles in patients with chronic obstructive pulmonary disease (COPD). Inspiratory muscle training (IMT) could improve the pressure-generating capacity of the inspiratory muscles. The purpose of this study was to determine whether combined CET and IMT would lead to additional benefits compared with CET alone in patients with COPD. In addition, the effect of combined training was compared between patients with and without respiratory muscle weakness. Methods: 73 patients with COPD were randomly divided into three groups: 25 patients received 8-week combined CET and IMT(combined group), 24patients received 8-week CET alone (CET group) and 24 patients did not receive any intervention (control group). Pulmonary function, exercise capacity, dyspnea, quality of life, respiratory muscle strength, emotional,nutritional status and BODE index were measured before and after pulmonary rehabilitation program. Results: After pulmonary rehabilitation, exercise capacity, dyspnea, quality of life, respiratory muscle strength, depression and anxiety, nutritional status all improved in the combined group and CET group compared with control group (P < 0.05). Inspiratory muscle strength significantly increased in combined group compared with CET group (75.30 AE 1.92 vs 71.04 AE 1.98 respectively;P < 0.05). However, there were no significant differences in other indices between two groups(P > 0.05). In both combined group and CET group, patients with weakened respiratory muscle had no greater benefits than those without weakened respiratory muscle (P > 0.05). Conclusions: Combined training is more effective in increasing inspiratory muscle strength compared with CET alone, but not in exercise performance, dyspnea, depressive symptoms and nutritional status. Further, IMT may not be useful when added to CET in patients with weakened inspiratory muscle. Background and Aims: Age is known to be a predictor of mortality and admission for exacerbations in subjects with COPD. Frailty is a geriatric syndrome originally defined by Fried as meeting three out of five criteria consisting of low unintentional weight loss, self-reported exhaustion, low grip strength, slow walking speed and low physical activity in 2001. However, alternative tools have been reported. One of them is the Kihon Checklist (KCL) questionnaire widely used in Japan to identify frail individuals and composed of 25 items with yes/no responses. We investigated the relationship between the KCL and clinical indices including Patient-Reported Outcomes (PROs) in stable COPD patients. Methods: We examined 54 consecutive outpatients with stable COPD. Participants completed the St. George's Respiratory Questionnaire (SGRQ), the COPD Assessment Test (CAT), the Hyland Scale, the Dyspnea-12 (D-12), the KCL, and pulmonary function tests. By the KCL (range, 0-25, with a high score indicating frailty syndrome), we categorized the participants into robust (0-3), prefrail (4-7), and frail (8-25), respectively. Results: We classified 26 (48.1%), 18 (33.3%), 10 (18.5%) participants as robust, prefrail and frail according to the KCL. There were statistically significant differences in the SQRQ total score, the CAT score, the Hyland Scale score, and the D-12 score among three groups. And the KCL score was significantly correlated with the SGRQ total score (R S 0.61, p < 0.01), the CAT score (R S 0.39, p < 0.01), the Hyland Scale score (R S 0.61, p < 0.01), and the D-12 score (R S 0.42, p < 0.01). Contrarily, we found neither significant between-group differences in pulmonary function measures including FEV 1 , FEV 1 /FVC, TLC, RV/TLC, IC, DL CO , DL CO /V A , nor noteworthy association between the KCL score and these spirometric measurements. Conclusions: The frailty screened by the KCL may be relevant to healthrelated quality of life and breathlessness in stable COPD patients. Background and Aims: Chronic obstructive pulmonary disease (COPD) has a high morbidity and mortality in the world, and COPD exacerbation is a crucial event for patients. The aim of this study is to investigate the factors affecting in-hospital mortality of patients with COPD exacerbations and to create a tool to predict individual outcomes with the patients' status on admission, using a nationwide inpatient database in Japan. Methods: We retrospectively collected data for patients who were admitted due to COPD exacerbation and were discharged between 1 July 2010 and 31 March 2013. Multivariable logistic regression analysis was performed to examine factors associated with in-hospital mortality. Results: There were a total of 3,064 eligible patients. In-hospital death occurred in 209 patients (6.8%). Higher mortality was associated with advanced age, male, lower BMI, disturbance of consciousness, severe dyspnea, history of mechanical ventilation, pneumonia, asthma on admission. Based on the result of multivariable logistic regression analysis, we developed a nomogram to predict in-hospital mortality. The concordance index of the nomogram was 0.775. The internal validation was performed by the bootstrap method with 50 resamples and the calibration plots are well fitted to predict in-hospital mortality. Conclusions: Our nomogram can predict in-hospital prognosis and may help clinicians to determine appropriate treatment. In the 40 min session, respiratory conditioning such as breathing retraining while walking and stretching training was mainly conducted one by one to decrease patient's exertional dyspnea. During the session, behavioral modification intervention was added to encourage patients to increase their physical activity using COPD diary and pedometer and an individual activity action plan was given. The interval of patient visit was 1 to 4 months. The classes for group patient education (60 min./session, 1/month, 4 times) was started from 2012 and 117 patients (COPD: 78 (66.7%)) were attended in the last three years. Results: The number of COPD-related hospitalization decreased from 104 (2011) to 72 (2014). There were significant reductions in the age group of seventies and eighties (p < 0.001). The DPC(Diagnosis Procedure Combination)COPD hospitalization Tokyo ranking released by the Ministry was the highest in 2012, however it was forth in 2012 and ninth in 2013, respectively. There was also 34% reduction in the number of hospitalization due to pneumonia (292 (2011), 304 (2012), 192 (2014) , respectively). Conclusions: It was suggested that the outpatient pulmonary rehabilitation with self-management education has the potential in preventing hospital admission of COPD patients. This labor-saving respiratory conditioning enhanced program will be helpful in spreading pulmonary rehabilitation. Background and Aims: Patient preference and satisfaction with inhalers may impact adherence to treatment and hence its outcome. 1 The ADVANTAGE study compared the preference for the feedback mechanism of the Breezhaler ® and Ellipta ® inhalers and the comfort of the devices' mouth piece in COPD patients' naïve to dry powder inhaler use. Methods: This open-label cross-over study randomized patients (≥40 years) with COPD [all severities as per GOLD 2014] and smoking history of ≥10 pack-years to use both the Breezhaler ® and Ellipta ® devices in differing sequences with a separation of ≥5 minutes between devices. After inhalation, patients completed a questionnaire 2 containing 4 questions capturing patients' perception of the feedback mechanism and comfort of the mouth piece. Questions were answered on a scale of 1 (lower preference) to 5 (higher preference) including perception of the feedback mechanism (mean of first three questions) and comfort of the mouth piece (fourth question). Wilcoxon signed rank test was used at a 2-sided 5% level of significance. Safety assessments included adverse events, physical examination, vital signs, height and weight. Results: One hundred patients (64 men and 36 women) with a mean (SD) age of 65.2 (9.07) years were randomized. 32 patients were current smokers and had a mean (SD) duration of COPD for 6.1 (4.82) years. Overall, patients reported the Breezhaler ® device to offer greater confidence of dose delivery and better comfort of the mouth piece (mean score 4.3 for both attributes) vs. Ellipta ® (mean score 3.6 and 3.9, respectively) ( Figure) . No safety signals were identified during the study. Background and Aims: Dyspnea is the main symptom of chronic obstructive pulmonary disease (COPD) and restricts activities of daily living (ADL). The Assessment of Motor and Process Skills (AMPS) is a standard measure of ADL. However, the association between AMPS and COPD remains unclear. The purpose of this study was to evaluate AMPS in in-home COPD patients and the associations between breathing function, dyspnea, quality of life, and disease-specific ADL standards. Methods: In this observational study, we included 13 outpatients with stable COPD without long-term oxygen therapy. Conclusions: AMPS correlated with a disease-specific ADL scale; this suggests that AMPS reflects ADL ability in stable COPD patients. Kobe University Graduate School of Health Sciences, Community Health Sciences, Kobe, Japan, 2 Home-visit Nursing Station Wakakusa, Home-visit Nursing, Nagano, Japan, and 3 National Hospital Organization Higashi Nagano Hospital, Internal medicine, Nagano, Japan Background and Aims: Long term oxygen therapy (LTOT) improves mortality in patients with chronic obstructive pulmonary disease (COPD). The adaptation standard of LTOT is PaO2 at rest; however, many COPD patients have hypoxia on movement and not at rest. Since 2004, we have provided home-nursing intervention programs for COPD patients after completion of pulmonary rehabilitation. These patients are routinely taken care of at home by home-nursing intervention while receiving continued in-hospital evaluation. The aim of the present study was to examine the effects of LTOT in COPD patients. Methods: COPD patients who participated in this program for 5 years were included in the study. Patients who dropped out during the 5-year period were excluded. The measurements included pulmonary function, arterial blood gas, 6-minute walking test (6MWT), activities of daily living (ADL) score, and health-related quality of life (QOL) score. First, the measurement results and the 5-year survival rates were compared between patients with and without LTOT. Second, they were compared between LTOT without desaturation (group A) during walking and no LTOT with desaturation (group B). The desaturation during walking was defined as SpO2 < 90% during 6MWT. Results: Forty-three subjects were included in the analysis. The 20 subjects with LTOT had significantly lower body mass index (BMI), SpO2 during 6MWT, and ADL scores than the 23 subjects without LTOT. The survival rate with LTOT (45%) was lower than without LTOT (69.6%). Six subjects were classified into group A and 11 subjects into group B. Group A had significantly higher SpO2 during 6MWT and PaO2 than group B but a lower survival rate (50% and 63.6%, respectively). Conclusions: LTOT improved hypoxia; however, it did not improve the survival rate of COPD patients. Although the efficacy of bronchodilator administration is established, treatment effectiveness can be compromised by patient preference and the skills required in using inhaler devices. It is important that an inhaler device is easy to use, so that the correct dosage is administered. This study compares the satisfaction and error occurrence of the three types of DPIs, namely Breezhaler, Ellipta, and Genuair. Methods: Healthy subjects aged over 40 and without experience in using DPI were recruited (n = 93). Subjects learned to use each DPI by reading the product instructions, followed by watching a demonstration with audio explanation. The DPIs were provided to the subjects in random order. The type and number of errors committed by the subjects were evaluated. Subjects were asked to complete a questionnaire to indicate their satisfaction and preference for various aspects of the DPIs. Results: Subjects rated significantly greater satisfaction on the indication for correct dose preparation for Genuair than Ellipta (5.84 vs. 5.13, p < 0.01). Genuair also scored significantly higher than both Ellipta and Breezhaler (5.59 vs. 4.69 vs. 4 .97, p < 0.01) when subjects were asked how confident they were to have inhaled the assigned dose. In terms of convenience, the numbers of subjects who preferred Breezhaler (35.5%) were higher than those for Genuair (32.3%) and Ellipta (22.6%). Most of the subjects preferred Ellipta (35.5%) for the ease of dose preparation. The overall satisfaction score for Genuair was significantly higher than those for both Breezhaler and Ellipta (78.6 vs. 69.5 vs. 72.2, p < 0.01). Conclusions: The use of Genuair DPI was associated with greater user satisfaction in healthy volunteers. This is important, as the satisfaction would improve patient compliance to inhaler therapy. Week 52 (p < 0.001 for both). IND/GLY showed significant improvement in SGRQ-C total score (−3.1 units; p = 0.006) and numerical reduction in rescue medication use (treatment difference: −0.25 puffs/day; p = 0.058) versus SFC. Pneumonia incidence was 3.6% with IND/GLY and 7.7% with SFC. Incidence of oral candidiasis was 1.2% with IND/GLY and 7.7% with SFC. Other adverse events (AEs) rates were generally comparable between IND/GLY and SFC, while severe AEs were numerically higher in SFC group. Conclusions: IND/GLY was better than SFC in terms of moderate/severe exacerbations, patient-reported outcomes and safety in Asian patients from the FLAME study. Study funded by Novartis Pharma AG. Background and Aims: The concentrations of cytokines is increased in the lungs of patients with stable chronic obstructive pulmonary disease (COPD), and is further augmented in airways during exacerbations. Nacetylcysteine (NAC) seems to be able to reduce COPD exacerbations, in addition to its well-known mucolytic activity, but the pharmacological mechanism for this effect is still unclear We aimed to pharmacologically characterize the anti-inflammatory effect of NAC in an ex vivo model of COPD exacerbation Methods: The influence of NAC was assessed on the contractile response and anti-inflammatory profile in human isolated bronchi incubated overnight with Krebs-Henseleit buffer solution (control) or lipopolysaccharide (LPS, 100 ng/ml) Results: NAC prevented the desensitization induced by LPS incubation on the contractile tone in a linear concentration-response manner (pEC 50 : 25Hz 5.5 AE 0.3, 50Hz 5.8 AE 0.4). Concentrations of NAC ≥300 μM inhibited the inflammatory response of human airways (IL-1β, IL-8, TNF-α: overall −55 AE 8%, P < 0.01 vs. LPS) induced by the overnight stimulation with LPS, whereas lower concentrations of NAC (≥1 μM) were sufficient to reduce the release of IL-6 (−33.2 AE 2%, P < 0.001 vs. LPS) elicited by LPS Conclusions: The results of this study demonstrated that concentrations of NAC >10 μM are needed to restore the normal contractile response of human bronchi challenged with LPS, and concentrations of NAC >300 μM are essential to obtain an anti-inflammatory response in an ex vivo model of COPD exacerbation Background and Aims: BACKGROUND Cigarette smoking is a major risk factor in the development of cardiovascular disease and atherosclerosis, chronic obstructive pulmonary disease (COPD). Extensive research has gone into identifying and attempting to validate relevant diagnostic biomarkers of disease activity and therapeutic response in chronic obstructive pulmonary disease. C-reactive protein (CRP), may be easily and sensitively measured in a variety of clinical situations to monitor disease progression. This study attempts to identify the relationship between smoking behavior and levels of CRP, focusing on the use of CRP measurement to predict long-term health in smokers. AIMS. To Compare CRP levels in asymptomatic smokers and nonsmokers,to compare lung functions spirometric values in asymptomatic smokers and nonsmokers and correlation of CRP levels and lung function values Methods: This is hospital based prospective study. 30 smokers and 30 non smokers above 18 years of age at a tertiary care Hospital were recruited. The mean CRP in smokers was 2.523mg/l (SD = 1.221) and mean CRP in nonsmokers was 1.318mg/l (SD = 1.394).The comparison was done using t-test for independent samples. There is significant difference in the average CRP values of smokers and non-smokers (p < .001). There is non-significant negative correlation between MMEFR and CRP (p > .05) in smokers. There is non-significant Negative correlation between MMEFR and CRP(p > .05) in non-smokers. There is significant difference in the average MMEF 75/25 values of smokers and non-smokers (p < .05). Conclusions: Our study demonstrates significant reduction in CRP in smokers and non smokers.Thus CRP can be a cheaper alternative biomarker for prognosis, drug development,and predictive outcomes in COPD. High sensitivity CRP is more sensitive and may be used as biomarker. Background and Aims: Chronic obstructive pulmonary disease (COPD) may have extrapulmonary manifestations including balance control, functional, and physical incapacities. Balance impairment is the risk of fall which has impacts on clinical outcomes such as activity-limiting daily living, depression and quality of life of COPD patients. To determine risk factors of balance impairment in COPD. Methods: The cross-sectional study was conducted at a single visit involving stable COPD patients with age more than 60 years old. Balance test was measured using the Berg Balance Scale (BBS), score of 46 and below indicated balance impairment. The clinically relevant data [age, sex, BMI, education, co-morbidity, PFT, severity of COPD, long-term oxygen therapy, history of fall, history of acute exacerbation, SGRQ score, CAT score, mMRC score, visual deficits, Timed Up and Go test (TUG), six-minute walk distance (6-MWD) and Hospital Anxiety and Depression Scale (HADS)] were compared between impaired and non-impaired balance patients by logistic regression analysis. Conclusions: Regardless of body weight, the presence of sarcopenia was associated with 2-4 times increased risk for decreased BMD in COPD. Baseline characteristics, number of exacerbations, pulmonary function tests, mMRC dyspnea scale, 6 MWD, CAT score and CCQ score before and after pulmonary rehabilitation program were assessed. Result: Most patients (97%) were male with median age 71 years. The mean forced expiratory volume at one second (FEV1) was 51.6 AE 24.2% predicted. After pulmonary rehabilitation, mMRC dyspnea scale and CAT score were statistically significant difference compared to before pulmonary rehabilitation with mean change 0.5 AE 0.9; p = 0.001 and 3.7 AE 5.6; p = 0.002, respectively. Only CAT score met the minimal clinically important differences (MCID). CCQ and 6 MWD were improved but no statistical significance. Pulmonary function parameters and number of exacerbations were not different between before and after pulmonary rehabilitation program. Conclusion: Out-patient hospital-based pulmonary rehabilitation program in COPD patients can improve quality of life in term of CAT score. Muang, Thailand, and 2 Maharat Nakhonratsima hospital, Medicine, Nakhonratsima, Thailand Background: Acute exacerbation of chronic obstructive pulmonary disease ( COPD ) is a leading cause of hospitalization and economic burden. Frequent exacerbations impair quality of life and effect decline of lung function. Objectives: We evaluated characteristics of COPD patients with acute exacerbation re-admitted within 28 days of discharge from hospital. The precipitating causes, acute management, hospital stay, outcomes and cost of admissions were also determined. Methods: The study population included COPD patients with acute exacerbation re-admitted within 28 days of discharge from Maharat Nakornratchasima hospital between 1 october 2013 and 30 June 2015. Retrospective descriptive study was applied. Results: 83 patients were re-admitted within 28 days of discharge due to acute exacerbation. Their mean age was 72.72 years and the male to female ration was 77:6. The both of admission were described as previous and re-admission. The mean duration of symptoms were 2.7 and 1.7 days respectively. 55.4% of patients in previous admission and 63.9% of patients in the re-admission had respiratory failure requiring mechanical ventilator. The most common precipitating cause was pneumonia which occurred 51.8% and 71.1% respectively. The organisms of pneumonia were identified in 58.1% patients of previous admission. Pseudomonas aeruginosa was prominent ( 20.9% ). In the re-admission, the most common organism was Acinetobacter baumannii ( 30.5% Background and Aims: There have been conflicting reports on the role of the NLRP3 inflammasome in IL-1-driven inflammation in COPD and cigarette smoke-induced injuries. We hypothesize that there would be activation of NLRP and/or alternative inflammasome types (including absent in melanoma 2, AIM2) in the airway of COPD patients or in response to cigarette smoke. Methods: Human cell lines and primary alveolar macrophages were analysed for release of IL-1β (ELISA) and its cleavage-activation, expression and localization of NLRP3, AIM2, ASC, and cleaved caspase-1 (immunofluorescence/confocal microscopy, Western blot). Effects of caspase-1 inhibitor (ZYVAD-fmk), NLRP3 antagonist (glyburide), and treatment with sphingosine-1-phosphate (S1P) or S1P receptor regulator FTY720, with or without exposure to cigarette smoke extract (10%, 24h), were investigated. Results: Cigarette smoke induced in human primary alveolar macrophages increase of IL-1β intracellular expression levels (24% and 2.6 folds in cells from two different donors, p < 0.05), and particles sizing 1-5um brightly stained for cleaved IL-1β both inside and outside the cell (4 and 6 folds, p < 0.001). These particles were partially co-localized with particulate NLRP3 or AIM2 which were shown sharply increased in cigarette smoke-treated cells. Cigarette smoke also induced NLRP3/AIM2asociated activation of IL-1β in THP-1 monocyte-derived macrophages, particulate NRLP3, AIM2 and active IL-1β seen mostly intracellularly. Release of IL-1β from cigarette smoke-treated cells was blocked by ZYVAD-fmk or glyburide. S1P or FTY720 (100nM) significantly protected THP-1 macrophages from cigarette smoke-induced activation of IL-1β (p < 0.05). Conclusions: IL-1-driven inflammation in COPD could be initiated by both NLRP3 and AIM2 inflammasomes, and regulated by sphingolipid signalling, which suggest novel therapeutic targets in COPD. Background and Aims: The incidence of both chronic obstructive pulmonary disease (COPD) and obesity are on the rise in Malaysia. To date there has been no study reporting spirometry airflow limitation that includes both restrictive and obstructive patterns in a non-selected population in Malaysia. The purpose of this study was to estimate the prevalence and risk factors of airflow limitation and screen for COPD using the new hand-held device AirSmart Spirometry and the COPD Population Screener (COPD-PS) questionnaire. Methods: A cross-sectional study was performed to screen non-selected population in two tertiary medical institutions in Malaysia (National University Malaysia Medical Centre and University Technology Mara, Hospital Selayang Campus) using a validated five-item questionnaire (COPD-OS) and the new AirSmart ® Spirometry device. Patient demographics were obtained using a standard questionnaire in which a face-to-face interview was conducted. Results: 265 subjects were recruited with 11% and 16% of the screened population observed as restrictive and obstructive patterns respectively. 20% of the screened population had COPD-PS score of more than 5. 74% of subjects with obstructive pattern were active or ex-smokers (p = 0.03, p < 0.01) whilst subjects with restrictive pattern were more likely to have a body mass index more than 23 (OR 2.52, 95% CI: 1.02-5.62)(p < 0.01). Using Spearman correlation analyses, there is a negative correlation between forced vital capacity and body mass index (rs = -0.5813, p < 0.001). Only one-fifth of the subjects with airflow limitation returned for formal assessment. Conclusions: This study reported a high prevalence of airflow limitation including restrictive lung disease the new AirSmart Spirometer. This study highlights high prevalence of undiagnosed COPD and high BMI as causes of airflow limitation in our population. Background and Aims: The proper spirometric method to define airflow limitation has been long-debated particularly over elderly population. We suspected the uncertain optimality of current thresholds may contribute to the controversy. Herein, therefore, the optimality of current threshold was investigated in fixed ratio (FR) and Z-score of FEV1/FVC (ZS). And also the preferred spirometric method in elderly population was assessed using threshold-free measure, the area under receiver operating characteristic curve (AUROC). Methods: Data were collected from the Third United States National Health and Nutrition Examination Survey. The Data from Non-Hispanic whites whose age was ≥ 65 was analyzed. ROC curves of both FR and ZS were plotted for 10-years all-cause, respiratory, and COPD mortality and the optimal threshold was assessed and compared to current one in each ROC curve. The preferred spirometric method was assessed by comparing the AUROCs of both methods. Results: Of 1,331 subjects, mean age was 71.7 AE 4.5 and 805 (60.5%) were male. Optimal thresholds of FR for 10-years all-cause, respiratory, and COPD mortality were 0.695, 0.615, and 0.615, respectively and all were lower than the current one, 0.700. Contrastively, those of ZS were -1.210, -1.492, and -1.413, respectively and all were higher than the current one, -1.645. No significant differences in AUROCs were observed between the spirometric methods for 10-years respiratory and COPD mortality (0.811 in FR vs. 0.806 in ZS, p = 0.350 and 0.895 in FR vs. 0.896 in ZS, p = 0.842, respectively). Figure 1 Comparison of AUROCs for 10-years respiratory mortality Conclusions: Current thresholds of both FR and ZS seem to be biased and may contribute to over-and under-diagnosis of airflow limitation in elderly population. Both methods showed comparable predictabilities for 10-years respiratory and COPD mortality, but we believe the convenient FR may be preferred by clinicians. Objective: To assess the efficacy and practicability of pr in severe copd in a limited resource setting. Methods: All new clinic attendants during last six months of 2015 with gold stage iii and iv copd were enrolled to the study. Patients with recent ischaemic heart disease, cardiomyopathy and severe pulmonary hypertension were excluded. They underwent a six week course of pr, which consisted of anterior chest wall, upper chest wall and diaphragmatic muscle strengthening exercises and pursed lip breathing, supervised by a trained physiotherapist. Available simple tools were graduated tension bands and free weights. Treadmill and ergometers were not available. Spirometry (using vitalograph alpha touch 65030 software version 1.72 ® ) and six minute walk test performed for all at the onset and end of pr. Results: 54 Patients (age 50-72 years; 51 males) were studied. Their initial mean forced expiratory volume in first second (fev1) was 41.46% of predicted for age and sex. 51 (95%) Individuals in the study showed an improvement in their fev1 at the end of the pr. Initial mean six-minute walking distance (6mwd) of the study group was 222.9 meters. At the end of six weeks mean 6mwd has increased to 242.7 meters (T = -1.6253; P = 0.0535). Conclusions: A short course of pr in severe and very severe copd resulted in an improvement of fev1 and 6mwd in this study. An effective low cost pr programmed could be easily set up with minimum resources in an appropriate clinical setting. Sanglah General Hospital, Radiology, Denpasar-Bali, Indonesia Background and Aims: Idiopathic Pulmonary Fibrosis (IPF) is a disease of unknown etiology with considerable morbidity and mortality, characterized by profound changes in lung morphology including excessive extracellular matrix deposition, myofibroblast foci, alveolar epithelial cell hyperplasia and extensive remodeling. One of difficulties in conventional imaging (MSCT and HSCT) is that IPF's radiological pattern is looks like usual interstitial pneumonia. Due to the limitation of conventional imaging, thus, in this paper, we would like to introduce Acoustic Radiation Force Impulse (ARFI) Elastography as elasticity-based imaging, usually for biomarker of liver fibrosis, now we used for novel biomarker in lung fibrosis. Methods: Eighty-one patients who had been diagnosed with idiopathic lung fibrosis were recruited and the stage of fibrosis was determined by biopsy. The diagnostic accuracy of FI, FibroScan and ARFI, as well as that of the combination of these methods, was evaluated based on the conformity of the results from these tests with those of biopsies. Results: Lung phenotype in IPF is characterized with patchy, predominantly peripheral,subpleural,bibasal reticular abnormalities with peripheral reticular opacities (48%). Furthermore, using lung biopsy, we can find thickening of lung parenchyme and with excessive growth factors of fibroblasts. This reason makes patient's lung looks stiff and rigid. By using ultasonic wave propagation produced by ARFI Imaging, the calcification and fibrosis level can be measured with Shear Wave Velocity (SMV). SWV is correlated with fibrosis (r = 0.717, p < 0.0001) and necroinflammatory activity of lung (r = 0.328, p = 0.014). Using these criterias, ARFI Imaging can be strongly comparable with lung biopsy in their diagnostic accuracy for prediction of severe fibrosis in IPF. Conclusions: SWV indicator caused by ultrasonic wave propagation in lung tissue can be used to quantify the shear modulus of lung tissue, based on lung elasticity and level of fibrosis/calcification. ARFI modalities are being studied as non-invasively diagnostic tool for IPF without necessity for lung biopsy. Background and Aims: Naval divers uniquely adapted to hypoxemic in terms of pulmonary vasculature. Pulmonary vascular endothelial and epithelial nitric oxide (NO) impairment can increase pulmonary artery pressure (PAP), leads to pulmonary hypertension. In the previous study, the effectiveness of hyperbaric oxygen therapy (HBO 2 T) on selected divers suffering pulmonary hypertension remains controversial. The aim of this study was to assess the usefulness of HBO 2 T in the secondary prevention of pulmonary hypertension among naval divers. Methods: 72 consecutive naval divers with pulmonary hypertension (mPAP > 25 mmHg) who met the inclusion criteria were entered in this non-randomized controlled clinical trial. The patients were randomized into two groups, as follows: 1) experimental: received 2.5 ATA hyperbaric chambers with 96% oxygen supply via oxygen hoods + Sodium Beraprost, 2) control: received only Sodium Beraprost. Pulmonary artery pressure was measured by echocardiography before each HBO 2 T session every 4 weeks until 1-year follow-up. Results: Before the first treatment session with HBO 2 T, the average systolic (sPAP), diastolic (dPAP), and mean (mPAP) arterial pressure were similar in both groups. The average mPAP was significantly lower in experimental groups after at least 3-months treatment duration (p-value = 0.05) until 1-year follow up (p-value = 0.01). After 1-year follow up, the values of sPAP (22 + 6 vs 36 + 7 mmHg), dPAP (9 + 4 vs 16 + 3 mmHg) and mPAP (14 + 4 vs 24 + 4 mmHg) were marked lower significantly compared to control groups. Conclusions: Our results demonstrated that HBO 2 T can reduce pulmonary artery pressure significantly. This is a pilot study for effectiveness of HBO 2 T in pulmonary hypertension; need to be caution in interpreted. Background and Aims: For more than 2 decades, resurgence of much technological advancement in the field of radiology has enabled it to play an indispensable role in aiding in the diagnosis and follow up of many respiratory disorders. Above all, High Resolution Computed Tomography (HRCT) is a vital tool in the arsenal of investigation available to the physician in evaluating the lung interstitium. Ground glass opacities (GCO) is a radiological descriptive term used rather commonly and occasionally indiscriminately by clinicians. It is defined as a hazy area of increased lung attenuation without obscuring the underlying vasculature. It is a non specific finding which can result from abnormalities involving the alveolar spaces, interstitium or combination of both. However, its significance lies in indicating presence of active and potentially treatable pathologies. Results: We highlight several interesting cases of ground glass opacities and its mimicker, with elaboration on the additional ancillary features and we propose a practical algorithm to approach GCO. Conclusions: Early recognition of ground glass opacity and its etiology enable early intervention in these group of patients. Background and Aims: Sirolimus has the first approved in Japan as a drug for the treatment of lymphangioleiomyomatosis (LAM) in 2014. We have treated 55 cases with LAM using sirolimus from April 2007 to April 2016. We retrospectively reviewed all patients, in order to clarify the incidence and clinical feature of sirolimus-associated interstitial lung disease (S-ILD). Methods: We reviewed clinical course, high-resolution computed tomography (HRCT), sirolimus concentration of patients experienced S-ILD by medical records. And we also evaluated serum biomarkers including Krebs von den Lungen-6 (KL-6), surfactant protein (SP)-D, SP-A. Results: We had experienced 5 patients (9.1%) with S-ILD. All patients were female with sporadic LAM and median age was 41 year-olds (range 35 -63). Median period between starting sirolimus and onset of S-ILD was 6 months (range 1.5 -22). One symptomatic patient, who had a fever and dyspnea on exertion with diffuse ground glass opacities (GGO) in HRCT, was effectively treated with high dose corticosteroid. She has been received treatment of low dose sirolimus for one year after onset of S-ILD. One asymptomatic patient with mild GGO improved by stopping sirolimus, and did not worsened again after restart of sirolimus. Three patients with localized consolidation in HRCT had spontaneous remission remaining treated sirolimus, despite the inefficiency of antibiotics. Median concentration of sirolimus was 6.9 ng/ml (range 4.7 -13.7). Median concentration of serum KL-6, SP-D, and SP-Awere 484 IU/L (range 262 -673), 66 ng/ml (range 17. 3 -196.9 ), 38.4 ng/ml (range 16.8 -115), respectively. The symptoms and opacities in HRCT were completely improved in all patients within 6 months. Conclusions: We have experienced 3 patients with asymptomatic localized consolidation (Grade 1) continuing sirolimus, and 2 patients with GGO stopped sirolimus including severe S-ILD (Grade 3) with corticosteroid. All patients with S-ILD could be received re-administration of sirolimus. Background and Aims: This study was performed to evaluate cardiomyopathy in patients with collagen vascular disease-associated interstitial pneumonia(CVD-IP) by thallium-201 myocardial scintigraphy and 123Iβ-methyl-iodophenyl pentadecanoic acid scintigraphy. Methods: thallium-201 myocardial scintigraphy and 123I-β-methyliodophenyl pentadecanoic acid scintigraphy was carried out for the patient diagnosed as CVD-IP. Results: It was performed on 3 patients(granulomatosis with polyangiitis: 2, and rheumatoid arthritis:1).No patient have cardiomyopathy. Conclusions: It will be necessary to collect cases for assesment of evaluation of cardiomyopathy in patients with CVD-IP. Background and Aims: Pulmonary Langerhans Cell Histiocytosis (PLCH) is a rare disease characterized by the accumulation of inflammatory and Langerhans cells in the bronchioles and alveolar interstitium, resulting in the formation of nodular inflammatory lesions. This paper reports a case of a 30 year old Filipino male presenting with recurrent bilateral pneumothorax. Methods: The patient was previously admitted in another hospital due to recurrent pneumothorax (bilateral in November 2013 and right-sided in December 2015). He was advised to undergo lung biopsy but was lost to follow-up. In January 2016, he consulted our institution due to recurrence of bilateral pneumothorax for which bilateral chest tubes were placed. Results: Chest x-ray showed extensive bilateral cystic lucencies in both lung fields while chest tomography revealed coarse reticular lesions in both lungs with interspersed cystic lesions and chronic volume loss with traction bronchiectasis intermixed with areas of ground glass opacities. The pulmonary function test showed severe restrictive ventilatory defect with severe reduction in DLCO (33%). Due to history of recurrent pneumothorax, he underwent video-assisted thoracic surgery with lung biopsy. Histopathology and immunohistochemistry staining with S100 protein showed acute eosinophilic and interstitial pneumonitis and granuloma formation, consistent with Pulmonary Langerhans Cell Histiocytosis. He was then started on Prednisone at 1mg/kg/day. He was discharged improved and stable. Two months after discharge, he again developed progressive dyspnea and cough. He again had recurrence of pneumothorax for which chest tube was placed and eventually underwent pleurodesis. The possibility of lung transplant was also discussed to the patient and his family. However, despite medical management, there was persistent and progressive dyspnea for which he eventually succumbed to death due to development of acute respiratory failure and tension pneumothorax. Conclusions: PLCH is a rare lung disease and its course is unpredictable for it can be quiescent spontaneously or can progress inevitably causing complications including death. Background and Aims: Radiation pneumonitis and pulmonary fibrosis are severe complications of large administered activities of 131 I. Herein, we presented a patient with papillary thyroid carcinoma, who developed interstitial pneumonia following lowdose of radioiodine therapy. Methods: A 36-year-old man received a near-total thyroidectomy and functional lymph node resection in February 2014 for papillary thyroid carcinoma which had no metastases in another hospital. 75 mCi 131 I was initially given in June 2014 and ten days later, the patient had a mild shortness of breath, then he accepted oral antibiotic therapy for several days. In July 2014, 131 I treatment was repeated periodically every other month, unfortunately, he developed dyspnea on exertion. Chest computed tomography (CT) scan was described as "mesh like shadow, stripe and patch in both lungs". Furthermore, he accepted intravenous methylprednisolone 80 mg/d and some antibiotics for ten days. His shortness of breath progressively increased and he could not walk any more. Additionally, chest CT scan also demonstrated diffuse interstitial pneumonia. When he came to our clinic, his hypoxia continued to deteriorate and he couldn't tolerate pulmonary function test. Blood gas analysis demonstrated pO 2 63 mmHg under oxygen therapy. The relevant laboratory tests excluded tuberculosis, viral infection, cardiac disease and connective tissue disease. After the higher dose methylprednisolone anti inflammatory therapy (360 mg/d × 3d ! 240 mg/d × 3d ! 120 mg/d × 3d), his condition was improved and he could walk independently. Then methylprednisolone was adjusted to oral administration and gradually reduced. Results: Three months later, chest CT scan demonstrated diffuse interstitial pneumonia was significantly reduced. He could walk upstairs. Conclusions: Interstitial pneumonia really happened to him indicating that low -dose 131 I possibly induces severe side effects in papillary thyroid carcinoma patients. Doctors should pay more attention to pulmonary complications of 131 I. National University Health System, University Medicine Cluster-Division of Respiratory & Critical Care Medicine, Singapore, Singapore, 2 National University Health System, Department of Diagnostic Imaging, Singapore, Singapore, and 3 National University Health System, Department of Pathology, Singapore, Singapore Background and Aims: An early and accurate diagnosis in interstitial lung diseases (ILD) is essential in the initiation of disease-specific therapies and optimising patient management. Current guidelines recommend a multi-disciplinary team (MDT) approach involving experienced pulmonologists, radiologists and pathologists in improving the diagnostic confidence of the various ILD. Aims: We review the ILD cases and outcomes presented at our MDT meetings, and determine if discussion resulted in a consensus on diagnosis and recommendations on subsequent patient management. Methods: We report a retrospective review of patients' medical records and MDT meeting discussion and outcomes from April 2015 to June 2016. The MDT consisted of pulmonologists, 2 radiologists and a pathologist. Results: A total of 58 patients were referred for MDT discussion from April 2015 to June 2016, of which 7 patients had histological specimens available for discussion. MDT discussion led to a consensus in diagnosis in 43 (74%) of the cases. 15 (26%) patients had usual interstitial pneumonia/ idiopathic pulmonary fibrosis, 8 (14%) had non-specific interstitial pneumonia, 7 (12%) had ILD related to underlying connective tissue diseases, 3 (5%) had combined pulmonary fibrosis and emphysema and 12 (21%) had undefined ILD. In addition to providing consensus on diagnosis and guiding condition-specific treatment, those with undefined ILD had recommendations on possible differential diagnoses and further investigations to derive a diagnosis. Conclusions: MDT discussions resulted in a consensus on diagnosis in the majority of the cases referred. A significant proportion of patients had undefined ILD who required additional clinical information and follow-up. Further studies are needed on the impact of MDT on subsequent management and patient-related outcomes. Background and Aims: The reports of methotrexate-associated lymphoproliferative (MTX-LPD) disorders are increasing. Although MTX withdrawal is known to have a moderate effect on tumor regression, no appropriate treatment and predictive factors of tumor regression has yet been established about MTX-LPD with lung lesions. Methods: We retrospectively evaluated 6 cases of MTX-LPD with lung lesions. Results: Median age was 74 years (range 65-84), and male-to-female ratio was 1:2. The preceding autoimmune disease was rheumatoid arthritis in all cases. Median period from the diagnosis of rheumatoid arthritis to the onset of MTX-LPD was 10.5 years (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) . Median period of MTXadministration was 7.5 years (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) , and median cumulative MTX dosage was 3493 mg (1340-6240). Multiple pulmonary nodules were 3 cases, and solitary pulmonary nodule were 2 cases. Hilar mediastinal lymph node enlargement was one case.The histological type of lymphoma was diffuse large B-cell lymphoma in 2 cases, T cell rich B-cell lymphoma in one case, and only atypical lymphocyte in 3 cases. All cases could not be diagnosed by bronchoscopy. Four cases were EBV-positive, and 2 cases were unknown. After MTX was stopped in all cases, tumor shrinkage occurred in 5 cases, but one case died after 3 weeks. Lymphocyte recovery at two weeks after MTX withdrawal was higher in cases with tumor regression (median increase, 1217/μL) than in that without tumor regression (395/μL). Lactate dehydrogenase, serum soluble interleukin-2 receptor was higher in the case without tumor regression than in those with tumor regression. Conclusions: Although our study was small, our results indicated that poor lymphocyte recovery after MTX cessation might be associated with tumor progression. Further study is warranted to determine MTX discontinuation and subsequent chemotherapy. Fibrotic change in CPFE is most commonly attributed to cigarette smoke, while its definition could include pulmonary fibrosis in a variety of diseases such as collagen disease and hypersensitivity pneumonitis. Pigeon IgG antibody is a known diagnostic tool for bird-related hypersensitivity pneumonia (BRHP). We assessed the significance of serum pigeon IgG antibody level in CPFE patients. Methods: A single-center retrospective cohort study was conducted. From 265 diagnosed interstitial pneumonia patients in our hospital, we extracted cases with CT findings characteristic to CPFE and with serum pigeon IgG antibody measured between 2014 May and 2015 June. Subsequently, we investigated the relationship between serum pigeon IgG antibody levels and days until the first CPFE exacerbation. Results: In total, 72 CPFE cases (male = 68, female = 4) were included into the final analysis. Median age was 73 years. Seventy-one patients had current or former history of smoking, with median amount of 49.5 packyears. Eight patients experienced exacerbations during follow-up after the measurement of pigeon IgG antibody. Secondly, we classified CPFE population into three groups according to pigeon IgG antibody levels (low n = 24, medium n = 24, high n = 24). Median pigeon IgG antibody levels in these groups were 8.0 mgA/L, 15.9 mgA/L and 33.7 mgA/L, respectively. Kaplan-Meier curve showed significantly earlier exacerbations in highpigeon IgG antibody group compared with low or middle group. Conclusions: In CPFE patients, high serum pigeon IgG antibody was a risk factor for exacerbation. CPFE population could be consisted of various patients including BRHP, who could respond to removal of antigens. Background and Aims: PAI-1, which is the target for diagnosis and treatment of acute lung injury, is the inhibitor of urokinase plasminogen activator receptor (uPAR). Complement factor D (CFD) is a component of the alternative complement pathway best known for its role in humoral suppression of infectious agents. The objective of the present study is to detect the expression of uPAR and CFD in Ischemia-reperfusion Lung Injury (IRLI) and investigate their potential roles. Methods: Human pulmonary microvascular endothelial cells (HPMEC)(1 × 10 5 cell/ml)within 5 passages were used in the present study. In vitro, we firstly divided the cells into normal and IRLI group, and then constructed IRLI model. HPMECs in Normal group were cultured in the carbon dioxide incubator using complete medium. On the other hand, cells in IRLI group placed in the incubator without oxygen were used medium without glucose for 6h. Next, all the cells were reperfused with complete medium in the carbon dioxide incubator for 12h. We observed the cells with a optical microscope. Finally, the expression of uPAR and CFD were examined by using RT-PCR and Western Blot methods. Results: IRLI model in HPMEC was successfully constructed with 6h Ischemia and 12h reperfusion. Furthermore, compared with normal group, the expression of uPAR and CFD in IRLI HPMEC were significantly decreased (P < 0.05). In addition, such an decrease in mRNA level was in line with change in protein expression. Conclusions: In IRLI, the expression of uPAR and CFD were significantly decreased compared with normal group, which indicated that decreased uPAR and CFD may induce inflammation in IRLI. Therefore, uPAR and CFD have the potential to be used in early diagnosis and treatment of lung injury. Background and Aims: Mizoribine (MZR), an immunosuppressive drug, has been proven to be effective in patients with nephrotic syndrome and rheumatoid arthritis. Since MZR gives less serious adverse events than often-used immunosuppresants such as calcineurin inhibitors, MZR could be administered in patients with interstitial pneumonia (IP)as an alternative. Little is known about how MZR works and behaves in patients with IP. Therefore, we investigated the efficacy and safety of MZR in patients with IP. Methods: Twenty-four patients with IP were treated with MZR from January 2011 to December 2015 at our institute and were evaluated retrospectively. Twelve patients had idiopathic IP and 12 patients had connective tissue disease related IP (6 DM/PM, 3 RA, 1 SSc, 1 SjS, 1 SLE). Background of administering MZR, effects of MZR and frequency of side effects were investigated. Results: MZR was added on to steroid monotherapy (n = 11) and steroid plus immunosuppresants (n = 2). In 11 patients, MZR was substituted for prior immunosuppresants (8 Cyclosporine (CyA), 3 azathioprine) because of their side effects or physicians' avoidance of possible future risk. With regard to efficacy, MZR improved or prevented worsening in 15 patients. Three patients presented with progressive IP in spite of adding MZR. One patients was unable to continue MZR because of severe rash. Conclusions: In our patients with IP, MZR was administered effectively and safely. MZR could be an alternative to often-used immunosuppresants in the management of IP. Background and Aims: We reported that the power spectrum (PS) of lung sounds in interstitial pneumonia (IP) reflected the intensity of fine crackles. The typical PS of fine crackles showed a sound peak around 1000 Hz and a dip around 500 Hz. (JRS 2015 (JRS , 2016 We tried to clarify the change of PS during the acute exacerbation (AE) of IP. Methods: We examined 17 cases of IP who experienced AE. Among them, ten patients improved, two stayed the same condition and five patients deteriorated clinically. Clinical improvement and deterioration was judged by subjective symptoms, vital signs and x-ray findings. We analyzed lung sounds of ten seconds of recording from bilateral lung bases by a sound-spectrometer (LSA2012, Kenz-Medico). We measured sound power of three frequency ranges, i.e., low 200-390Hz, middle 400-790Hz (MFP) and high 800-1600Hz (HFP) and compared MFP and HFP (dBm) before and after the treatment including steroids and immunosuppressive agents. Results: In improved patients the MFP before and after treatment was -13.3 (dBm) and -20.3 and the HFP before and after treatment was -21.8 and -31.9. In stable patients the MFP before and after treatment was -19.6 and -12.1 and the HFP before and after treatment was -19. 3 and -7.9 . In deteriorated patients the MFP before and after treatment was -15.6 and -1.9 and the HFP before and after treatment was -23.4 and -6.8. There was a decrease of MFP and HFP in improved patients while there was an increase of MFP and HFP in deteriorated patients. Conclusions: We conclude that PS, especially the MFP and the HFP in patients with IP is a useful parameter to detect improvement and deterioration. These results suggest that when listen to lung sounds of patients with IP, the patients are improved when lung sounds become softer and they are deteriorated when lung sounds become louder. Background and Aims: Detailed body composition, such as fat-free mass, has not been examined in idiopathic pulmonary fibrosis (IPF). We investigated whether the fat-free mass index (FFMI), an index of lean body mass, predicted survival. Methods: Forty-four patients with IPF were enrolled in the study. Their body composition was assessed using direct segmental multi-frequency bioelectrical impedance analysis. The degree of correlation between variables of body composition and other variables such as physiology and survival was examined. Results: There was a significant positive correlation between FFMI and FVC, DLco, and 6-min walk distance, and a significant negative correlation with age. However, there was no significant correlation between FFMI and either percentage predicted FVC or DLco, with the degree of correlation being similar to that observed with body mass index (BMI). BMI and FFMI showed no significant correlation with any patient-centred outcomes including dyspnoea, health-related quality of life, anxiety, and depression scores. A univariate Cox proportional hazard model showed several variables, but not BMI, were associated significantly with survival. FFMI (HR: 0.64, 95% CI: 0.43-0.94, p = 0.02) and FVC percentage predictive (HR: 0.96, 95% CI: 0.93-0.99, p = 0.008) were significant factors in a multivariate model. Conclusions: We conclude that FFMI is a significant predictor of survival in patients with IPF. Background and Aims: Fine crackles are brief, discontinuous highpitched lung sounds and are heard in patients with interstitial pneumonia (IP), while coarse crackles are loud and low-pitched and are heard in patients wtih bacterial pneumonia(BP). These descriptions are subjective auscultatory findings and are needed to be defined by lung sound analysis. We tried to clarify the difference of fine and coarse crackles by analyzing these adventitous lung sounds by sound spectrogram, especially by their power spectrum distribution. Methods: Seventeen subjects with IP who have honeycombing in their chest CT and four subjects with acute pneumonia were examined. We recorded analyzed lung sounds from bilateral lung bases in patients with IP and affected area in patients with BP. We analyzed breath sounds by sound spectrometer (Kenz Medico, LSA 2010) and examined their frequency-power distribution (power spectrum: PS). Results: Ten patients with IP had power peak at around 1000 Hz and power dip at around 500Hz and showed reversed S shape ( Figure) graphically while seven patients with IP showed 1000 Hz peak without 500 dip thus no reversed S shape. All the patients with IP showed strong sound power in higher frequency range, i.e., between 500 Hz and 1300 Hz. Four patients with BP showed PS gradual tapering of sound power above 500 Hz. Conclusions: Fine crackles in patients with IP showed strong sound intensity above 500Hz while coarse crackles in patients with BP showed sound attenuation above 500Hz. PS by lung sound analysis is a useful tool to differenciate between fine crackles and coarse crackles objectively. Background and Aims: Patients with interstitial pneumonia (IP) is reported to have poor sleep quality. However, so far, it is believed that reduced caudal traction on the upper airway due to the decrease of lung volumes can enhance collapsibility. Less understood is the association between impairment of pulmonary function in interstitial pneumonia and sleep breathing disorders (SBDs). This study is to clarify relation apnea-hypoxia index (AHI) and pulmonary function in patients with IP. Methods: We assessed pulmonary functional test and AHI using overnight portable monitoring device SAS-3200 (Nihon Kohden, Inc., Tokyo, Japan) equipped with heart rate, airflow sensor, snore, body position, respiratory effort and percutaneous saturation (SpO 2 ) at the same day. Correlation between AHI and FEV 1 /FVC, %VC, %DLco and %DLco/VA in pulmonary functional test were evaluated. Results: We enrolled 15 patients (53.3% were male, the mean age was 68.3 AE 13.1 years) who were diagnosed IP according to the highresolution computed tomography and restrictive impairment (%VC < 80%). In IP patients with restricted impairment, despite of no correlation between AHI and %VC, there was significantly negative correlation between AHI and %DLco/VA (r = -0.460, p < 0.05). .5 kg/m2(OR: 6.53 95% CI 1.32-32.33, P = 0.022) was independently associated with extensive pulmonarylesions involving more than four lobes. The decrease in cholesterol level, decrease in ratio of visceral fat volume and the percentage of subjects who changed from low INA to high INA were higher in NTM patients with disease progression than those with stable disease course (all, P value <0.05). In a multivariate analysis, a decrease in cholesterol concentration of >20 mg/dL was the predictive factor for disease progression (OR 10.08, 95% CI 2.36-43.15, P = 0.002). Conclusions: These findings suggest that the change in cholesterol level may be a marker of disease progression in patients with PNTM disease. Background and Aims: Organizing pneumonia (OP) secondary to Mycobacterium Tuberculosis (TB) infection has been recently reported and it accelerates the severity to the original infectious disease. This is a case series study and the aim of this study is to examine the effects of systemic steroid therapy to severe pulmonary TB infection with secondary organizing pneumonia. Methods: This is a case series study. Cases of TB infection with secondary OP treated with steroid in 2015 in our hospital were enrolled. Secondary OP was diagnosed with chest X-ray or CT and serum KL-6 or SP-D. Results: 47 y.o. male with TB past history admitted to Intensive Care Unit (ICU) with severe respiratory failure and bilateral consolidation in the chest CT. Steroid (80 mg/body) was started from admission day and the lung infiltration disappeared in a few days. 81 y.o. female with severe respiratory failure and bilateral infiltration in chest X-ray. Steroid (40 mg/body) was started from admission day and the lung infiltration disappeared in a few days. 91 y.o. female with miliary TB with consolidation in Chest Xray. Steroid (250 mg/body) was started on the 21st day of admission but she died 3 days later. 42 y.o. male with miliary TB admitted to ICU under respiratory ventilation control with bilateral lung consolidation. Steroid (80 mg/body) was started on the 12th day of admission but there was no effect and he died on the 50th day. We were not able to perform bronchoscopic evaluation such as TBLB or BAL for these patients because of their severity.Two cases treated with steroid from the admission day recovered very soon. However, two miliary TB cases treated with steroid 21 days and 12 days after admission were not able to benefit from steroid and eventually died. Conclusions: Early diagnosis and early treatment seems important for severe TB infection with secondary OP. Background and Aims: PF is a deadly disease to human health. Currently, effective treatment and therapies are eagerly needed. Improvement there should be on the animal model of drug evaluation. We had a drug evaluation on the rhesus PF models. The drug which we evaluated on the rhesus can simultaneously binds with TGF-β1 and VEGF with strong affinity called HB-002. We try to find out if it can slow down the progress of PF. Methods: We injected the BLM into the trachea with an atomizing injector to establish the rhesus PF model. 3 months after the BLM injection, HB-002 or placebo was given to these model monkeys 2 times a week by intravenous injection. We monitored the fibrosis progress by HRCT and levels of biomarker such as SP A, D, MMPs and SaO 2 , we also take the activity levels as a supplement. 8 months later, these monkeys were sacrificed, we have arterial blood gas analysis during the sacrificing. HE and Masson stain for pathological changes were performed. Protein levels were investigated. Results: We didn't see the significant differences of pathological changes between the HB-002 group and the placebo group through stains and HRCT. The arterial blood average pO 2 of the HB-002 group was better than the placebo group but no statistical significance. There were significant differences of the serum SP A and D levels between the 2 groups. 8 months after the beginning of HB-002 injection, the blood levels of SP-A and D were about 0.7-fold lower than the placebo group. After all we found the TGF-β pathway was partly blocked. Conclusions: The current studies show there might be a little useful for rhesus PF model. Now, we are doing researches with the rhesus PF model focusing on the lncRNA changes and the proteomics, and a new drug evaluation will come soon with enough time. Background and Aims: Tuberculosis (TB) is a global health problem with only 2.8 million bacteriologically confirmed pulmonary TB cases from 4.9 million pulmonary TB cases in the world. Most low and middle-income countries (like Indonesia) still use Acid-fast bacilli (AFB) assay to help diagnosing TB because simple, fast and low cost procedure. Nevertheless, diagnosis of TB with negative sputum AFB result (smear-negative) is difficult with most held unspecific clinical manifestations causing late diagnosis and therapy, increasing morbidity, mortality and transmission rate. As many as 36% cases in the world and 32% cases in Indonesia reported as smear negative TB cases, particularly in immunocompromised patients. Xpert MTB/RIF assay is a rapid molecular assay which can detect Mycobacterium tuberculosis (MTB) in 2 hours and has equivalent sensitivity as MTB culture. The purpose of this preliminary study is to evaluate the role of Xpert MTB/RIF assay for MTB detection in new presumptive tuberculosis patients with negative sputum AFB. Methods: Subjects (n = 31) are all presumptive tuberculosis patients (new case) based on clinical indications and AFB negative sputum results in Persahabatan Hospital, Jakarta, Indonesia. All 31 subjects are tested with Xpert MTB/RIF assay and MTB culture using their sputum samples. Results: The Xpert MTB/RIF final result among 31 subjects, were 27 subjects with MTB not detected, 1 MTB detected very low, 2 MTB detected low and 1 MTB detected medium. All 4 subjects with MTB detected has rifampicine resistance not detected. On the other hand, among those 31 subjects, there are 30 subjects with negative culture and 1 with positive culture. The one subject with positive culture has had MTB detected low in Xpert MTB/RIF assay. Conclusions: In conclusion, Xpert MTB/RIF Assay increases detection rate of MTB even in patient with negative sputum AFB. Background and Aims: Active tuberculosis patients often deteriorate even after induction of antituberculous medication. It is problematic because these patients need long-term hospitalization. Although some factors associated with vulnerability to tuberculosis infection and pathogenesis are elucidated, few reports show factors involving to the deterioration in active tuberculosis patients. This study was designed to elucidate factors for deterioration in active tuberculosis patients. Methods: From April 2009 to May 2016, all inpatients with active tuberculosis infection in the Ryukyu University Hospital were included in our retrospective study. All diagnoses were confirmed by the culture and/or polymerase chain reaction of tuberculosis. Medical records were reviewed to extract related clinical features. IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY: IBM Corp was used for statistical analysis. Results: In total 63 TB cases were collected (male: 35). The mean age of patients was 66.3 years old. Of those, 39 patients had acute respiratory failure. Univariate analysis showed that daily steroid (p = 0.002), daily nonsteroidal immunosuppressants (p = 0.018), sputum smear-positive (p = 0.028), higher age (p = 0.031) and lower serum albumin (p < 0.001) are related to acute respiratory failure. Multivariate analysis revealed that daily steroid (p = 0.022) and lower serum albumin (p < 0.001) are related to acute respiratory failure. The number of survivors and non-survivors were 56 and 7, respectively. Univariate analysis showed that maintenance dialysis history ≥ 3 months (p = 0.004), acute respiratory failure (p = 0.01), miliary tuberculosis (p = 0.021) and lower serum albumin (p = 0.003) are related to death. Conclusions: Our study showed lower serum albumin is related to risk factors for both acute respiratory failure and death. Multivariate analysis revealed that daily steroid and lower serum albumin are related to acute respiratory failure. Background and Aims: Rayong is province in Thailand which tuberculosis is still a major public health problem at local and national level. There is the highest number per 100,000 population of MDR cases in the country. Therefore, a fast and accurate diagnosis of MDR-TB is important for patient care and reduce the spread of infection to the community. Xpert ® MTB / RIF thus have a role in helping to diagnose tuberculosis, multidrugresistant. Objectives: Aims to evaluate diagnostic performance of Xpert ® MTB / RIF (sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), and posttest probability) in actual user experience in non-central part of Thailand. Methods: This study is a retrospective study between 1 August 2012 to 31 October 2013. Result of Xpert ® MTB / RIF test of sputum with clinically suspected MDR tuberculosis were included in study. This study used tuberculosis culture as a gold standard of diagnosis. Results: Total of 337 samples were included in study which were smear positive 205 samples. The number of HIV were 107 samples. The reason for the Xpert ® MTB / RIF test that most retreatment, failure of sputum conversion on third month and prison respectively. A total of 104 samples of 337 specimens were culture confirmed. The study showed that the sensitivity of Xpert ® MTB / RIF for MDR-TB diagnostic was 95.5% and 91.5% specificity. Accuracy of test was 92.3%. Negative predictive value 98.7%. But found positive predictive value (PPV) and posttest probability of 75% is not good. The ability to detect AFB staining in patients with HIV was only 64%,but if Xpert ® MTB / RIF was used in this group ability to detect tuberculosis up to 96%. Conclusions: The Xpert ® MTB / RIF for diagnosis of MDR-TB was effective better and faster.However culture is also required to confirm the diagnosis. Background and Aims: Propylthiouracil (PTU) used for hyperthyroidism. Numbers of PTU induced adverse reactions such as leukopenia, rash, arthritis, vasculitis, and lupus-like syndrome. PTU has been observed to be associated with antineutrophil cytoplasmic antibody (ANCA)-positive small vessel vasculitides. We describe here a patient with PTU-induced ANCA-positive vasculitis causing alveolar hemorrhage, which rapidly improved with cessation of PTU and administration of corticosteroids. Methods: A 57-year-old woman was admitted to hospital for evaluation of dyspnea for two weeks. Five months before admission she complained of cough with non-massive haemoptysis and weight loss. She had been diagnosed as having hyperthyroidism at the age of 55 and therapy with PTU, initial dose of 450 mg/day and decreased to 50 mg/day in six months and maintainance until admission. Physical examination revealed tachycardia (112/min), tachypnea (28/min), SpO2 = 88% (room air) and bibasilar crackles. Laboratory showed: anemia (Hb = 6.3 g/L), no microscopic heamaturia or proteinuria. P-ANCA was positive at a titer of 1:800 with anti-myeloperoxidase (MPO) was positive and ANA positive at low toter (1:80) . Chest x-ray and CT chest showed alveolar opacities in the middle and lower lobes of both lungs. Bronchoscopic findings showed sequential BAL were established consistent with alveolar hemorrhage. Lung biopsy was performed for exclude infection. BAL report indicated benign cytology and BAL culture was no organism. A diagnosis of PTU-induced alveolar hemorrhage, PTU was discontinued and prednisolone (50 mg/day) was started. After treatment gradual improvement within few week. Results: The presented patient developed a PTU-induced ANCAassociated vasculitis resulting in pulmonary hemorrhage with or without kidney involvement. Bronchoscopic finding and histopathology could be inconclusive, but detection of ANCA helped for diagnosis. Dramatic improvement after discontinuation of PTU and start treatment with high dose steroid. Conclusions: PTU-induced ANCA-associated vasculitis is important because the continued use of PTU can lead to life-threatening alveolar hemorrhage. Background and Aims: Idiopathic pulmonary fibrosis (IPF) is an incurable lung disease with lung tissue became thick and stiff, or scarred. Although great achievements have been made in terms of molecular diagnostics and pathobiology, underlying pathogenesis associated with IPF is still unclear and needs to be well defined. Methods: In this present study, both changes of microRNA (miRNA) and mRNA for IPF have been investigated using an integrative network approach. The original miRNA and mRNA expression profiling datasets were downloaded from Gene Expression Omnibus (GEO), and differently expressed miRNA/mRNA were identified using Significance Analysis of Microarrays (SAM) algorithm. Molecular targets associated with miRNA were expanded using Cytargetlinker in Cytoscape and finally validated using the mRNA array expression profiling. Results: This integrated miRNA-mRNA network encompassed 27 genes and 22 miRNAs associated with IPF initiation. Functional enrichment analysis indicated that Cytokine-cytokine receptor interaction and Glycine, serine and threonine metabolism signaling pathways were highly associated with IPF progression. This integrated network demonstrated the interaction between miRNA and genes, in particular, we highlighted miR-409-5p and has-miR-376c, and their target genes (CCL20 and OSM) which may shed new light for IPF initiation and development. Conclusions: Using the public available datasets from GEO database, we established a miRNA and mRNA interaction network for IPF, and screened out some miRNA candidatesand genes for IPF initiation and development, which may be served as potential targets for IPF diagnosis and therapeutics. A 38 year-old female presented with eight months history of progressive dyspnea with productive cough and significant weight loss. Heavy alcohol drinking and 10 pack-year smoking were noted. She received treatment from the nearby hospital. Left upper lobe consolidation with peri-aortic radiolucency was revealed on initial chest radiography. The decreased lung volume and juxtraphrenic peak sign were also noted. These findings were consistent with luftsichel sign. Her sputum AFB stain was positive and Mycobacterium tuberculosis complex was confirmed by cultivation. The standard regimen of anti-TB was given. Isoniazid, Rifampicin, Pyrazinamide, Ethambutol and Riboflavin was prescribed for being initial treatment. After for 2 months of treatment her symptoms subsided but she still had ongoing weight loss from 43 kg to 38 kg. Despite of the negativity sputum AFB, there was no improvement of chest radiography. Isoniazid and Rifampicin were given for being maintenance therapy. Computer tomography of chest was done. Persistent left upper lobe consolidation and atelectasis were detected. Lung mass with endobronchial obstruction was suspected. She was referred for further investigation with concerning of primary lung cancer. Despite that her medication adherence to treatment was very poor, the flexible bronchoscopy was performed. The narrowing of left upper lobe bronchus opening without endobronchial mass lesion was demonstrated from bronchoscopy. Histopathology from transbronchial biopsy at left upper lobe was consistent with chronic granulomatous inflammation. In addition, polymerase chain reaction for Mycobacterium tuberculosis was positive. Neither malignancy nor fungi was detected. Treatment of anti-TB was continued. In conclusion, the rare cause of luftsichel sign on chest radiography was confirmed with pulmonary tuberculosis. However malignant disease must be taken into account until prove to be otherwise. Background and Aims: PLCH is a kind of rare disease, particularly with multiple organs involved. Review the diagnosis and differential diagnosis of PLCH through a special case of PLCH associated with positive ANCA and asthma. Methods: One 44-year-old male was admission into the second hospital of Jilin University with chief complaint of paroxysmal wheezing for 2 years, and more serious dyspnea with cough and expectoration for 1 week. A month ago, central diabetes insipidus was diagnosed for this patient with appear polyuria, mild osteolytic destruction in the upper jaw and left acetabular bone, and multiple small pulmonary nodules. The patients had smoked for 20 packs.years without quitting. The meaningful results of auxiliary examination were as follows: multiple small pulmonary centrilobular nodules (1-10 mm) accompanied with small amount of small cystic changes were found in lung CT; bronchial dilation test was positive; lung diffusion function (DLCO%) was 65%; ANCA test was positive; eosinophil in peripheral blood was 8%; Langerhans'cells were seen intra alveolar exudate cells and a small amount of eosinophilic cells shown in biopsy of lung tissue by fibrobronchoscopy. Results: Diagnosis of the patient was PLCH involving multiple organs, also called eosinophilic granulomadisease. Significant improvement had been found in clinical manifestation and lung CT after 3 months treatment with prednisone (60 mg / day) and quitting smoking. Allergic granulomatosis and Churg-Strauss syndrome(CSS)should be considered for differential diagnosis in this case, because of association with asthma, increased eosinophils in blood and lung tissue, and positive ANCA. But PLCH was diagnosed in this case finally because of accompaning of central diabetes insipidus, osteolytic destruction, and pathological change with Langerhans'cells in alveoli specially. And it had been rarely reported that PLCH accompanied with asthma and positive ANCA measurement, so the possibility of PLCH combined with CSS should also be considered. The following up and instruction should be given continuously. Background and Aims: Diagnosis of tuberculosis is difficult because of the non-specific clinical presentation. Here we report two cases in which diagnosis was delayed due to cognitive bias. Methods: Case 1 An 82-year-old Japanese man with diabetic nephropathy presented with a several-week history of fever and back pain. On admission, he entered shock and antibiotics were administered. Blood pressure immediately improved, but fever continued. Needle biopsy at the fifth lumbar vertebra with compression fracture was performed on suspicion of pyogenic spondylitis, but no organisms were cultured with incubation for 1 week. One month after biopsy, acid-fast bacteria grew from the specimen and culture revealed tuberculosis. Chest computed tomography showed diffuse small pulmonary nodules. Acid-fast staining for sputum showed positive results. More than 70 days after the start of symptoms, miliary tuberculosis and tuberculous spondylitis were diagnosed. Case 2 A 75-year-old Japanese woman suffering from rheumatoid arthritis and interstitial pneumonia and taking prednisolone and salazosulfapyridine displayed moderate arthralgia, slight fever, and loss of appetite. Before starting biologics to reduce symptoms, chest computed tomography was performed to check for interstitial pneumonia. Computed tomography revealed nodular shadows in the right middle and left upper lobes. Finally, tuberculosis was confirmed on bronchoscopy. Results: In Case 1, tuberculosis was on the list of differential diagnoses, but antibiotics for the state of shock appeared effective, so we kept suspecting common bacterial infections due to anchoring bias. If we had been aware of the insidious progression, we could have detected tuberculosis before needing airborne isolation. In Case 2, we regarded fever and appetite loss as symptoms of uncontrolled rheumatoid arthritis due to availability bias and overconfidence bias, despite the cellular immune deficiency. Juntendo University Graduate School of Medicine, Department of Respiratory Medicine, Bunkyo-ku, Japan, and 2 Juntendo University Urayasu Hospital, Department of Respiratory Medicine, Urayasu-city, Japan Background and Aims: One of the Chinese traditional medicines, Nijutsu-to, is used for patients with osteoarthritis (OA). There are several case reports on the development of interstitial pneumonia or acute lung injury induced by herbal medicine, especially, Bofutsushosan, Syo-saikoto, and Goshajinkigan. However, it is unknown if Nijutsu-to induces pulmonary toxicity. Methods: We retrospectively reviewed two cases of acute respiratory failure after initiation of Nijutsu-to. Results: Two 80s Japanese men with OA received Nijutsu-to. Both patients developed acute respiratory failure several weeks after initiation of Nijutsu-to. They had a cough and dyspnea at the time of developing acute respiratory failure. Chest computed tomography findings showed diffuse ground glass opacity with traction bronchiectasis and serum KL-6 and surfactant protein-D levels increased in both patients. We clinically diagnosed these findings as diffuse alveolar damage (DAD). Therefore, one patient received steroid pulse therapy and cyclophosphamide, and the other was treated with only steroid pulse therapy. However, their symptoms, chest radiological findings, and desaturation acutely progressed. Although the two patients received mechanical ventilation, they died several weeks after developing acute respiratory failure. One patient's family consented to an autopsy. Pathological findings in the autopsy demonstrated capillary congestion, hyaline membranes, and interstitial/intra-alveolar edema, which are observed in the early exudative DAD phase on Elastica van Gieson (EVG) staining, and organization of exudates with the proliferation of fibroblasts on EVG staining, as observed in the late organizing fibrotic DAD phase. There was no finding of honeycombing. Conclusions: There are some reports on acute respiratory failure or development of interstitial pneumonia, probably induced by Radix Scutellariae, which is contained in herbal medicines, including Nijutsu-to. Chinese traditional medicine containing Radix Scutellariae should be carefully used because of its potential role in the development of DAD. Background and Aims: With widespread use of the molecular susceptibility test for the drug of mycobacterium tuberculosis (M.TB), it has been found that results of the test are not identical with them of a conventional, phenotypic susceptibility test Methods: From Aug. 2010 to Jan. 2016, TB patients who were performed the two drug susceptibility tests (DST) for M.TBi.e. molecular tests such as MTBDRplus for isoniazid (INH) and rifampicin (RFP) or GeneXpert for RFP, and phenotypic test-were collected and their medical records were reviewed retrospectively in a tertiary hospital. Results: Among 859 TB patients, 49 patients (5.7%) were enrolled. Their mean age was 55.7 year-old and thirty were male. The underlying diseases were as follows; diabetes (9 cases), COPD (6), lung cancer (2), other malignancies (9).10 cases were MDR-or XDR-TB. As for the discordant pattern, the DST results for INH showed more inconsistent than those for RFP between the two tests. Whereas 25 cases had INH susceptible (S) in MTBDRplus and INH resistant (R) on phenotypic test, 15 cases had INH R in the former and INH S in the latter. As for RFP, 10 cases were R in in MTBDRplus with S in conventional DST and two cases were inverse. Among the 43 cases which were recognized the final results of the two types of DST, 32 patients (74%) were treated by phenotypic results. Clinical response for TB control was treatment success (26 cases), failure (3), follow-up loss (5), death (2), and on-going treatment (11). Conclusions: It might happen a situation with inconsistent data between the two types of DST for M.TB, especially as for MDR or INH drug. Until now, the result of conventional DST was considered more important than it of molecular DST in a real practice. More studies about clinical impact of inconsistency are required to confirm the better DST Background and Aims: The airway complications after heart-lung transplantation usually relate to anastomosis ischemia and infection. The reported incidence varies among centers. Tracheal anastomotic infection can lead to major airway complications such as necrosis or dehiscence. Bacterial infection is more common. However, Aspergillus infection has been reported to cause subsequent airway complications. We report a case of 42-year-old woman who has been undergone heartlung transplantation for 6 years. The patient presented with non-massive hemoptysis with acute diarrhea, fever and later developed acute respiratory failure which required mechanical ventilation. Initial investigation revealed pulmonary Mycobacterium avium complex (MAC) and Aspergillus spp.infection The patients was treated with antibiotics and antifungal agents. During admission, the patient complained of chest discomfort and had recurrent right pneumothorax.Bronchoscopy was performed after extubation and tracheal ulcer was found at tracheal anastomosis. Tracheal biopsy was done and the tissue pathology revealed intracellular organisms with morphology compatible with Histoplasma spp. Then, antifungal agent was changed to amphotericin B. Follow up bronchoscopywas done at one month later and demonstrated an improvement of tracheal ulcer. Conclusions: The Histoplasmosis is a rare cause of tracheal infection and should be considered in immunosuppressed patients. Background and Aims: Vitamin D enhances host protective immune responses to Mycobacterium tuberculosis by reducing disease associated inflammation in the host. The aim of this study to compare the vitamin D group of pulmonary tuberculosis patients with a placebo group in terms of sputum conversion, and radiological improvement. Methods: Sixty four pulmonary tuberculosis patients visiting several clinical public health in Medan, from April 1st to June 31st, 2016 were included in this study. The subjects were randomised to receive vitamin D3 2,5 /oral or placebo in a single blind method, at baseline and 14, 28, and 42 days after starting standard tuberculosis treatment. The primary endpoint was time from initiation of antimicrobial treatment to sputum culture conversion. The rate of sputum conversion and radiologic examination were evaluated. Results: 64 patients were included in the primary efficacy analysis (32 assigned to intervention, 32 assigned to placebo). Median time to sputum culture conversion was 28 Á 0 days in the intervention group and 42 Á 0 days in theplacebo group. There is 88,7% of the vitamin D group and only 74.7% of the placebo group had sputum conversion.This difference is statistically significant (p = 0.002). Improvement in radiographic findings in the group with vitamin D is also higher in second month (74% vs.43%, p = 0,06). Conclusions: Vitamin D has supportive effects in pulmonary tuberculosis patients by improving healing process as indicated by faster improvement in sputum conversion and radiographic. Background and Aims: Leptospirosis is the most widespread zoonotic disease in the world. As this disease is often multisystemic with a wide variety of clinical signs and symptoms, diagnosis can be difficult and may be confused with other diseases. We present to you a leptospirosis case causing polyserositis which is a very unusual finding and is the only second case in the world to be reported. The first case was reported in Istanbul and unfortunately the patient succumbed. Methods: We report a case of a 24 year old Malay male. He presented with 2 weeks productive cough, pleuritic chest pain, and fever. On examination he was tachypneic. Auscultation of his lungs showed reduced breath sound bilaterally. He later developed septic shock, acute kidney injury, confusion, respiratory distress, which required intubation and mechanical ventilation. He had deranged coagulation profile, leucocytosis, bicytopenia, transaminitis, CXR and CT thorax showed bilateral pleural effusion, echocardiogram showed massive pericardial effusion corresponding to his pericardial tamponade. Pleural fluid and pericardial fluid analysis consistent with exudative picture. All cultures yield no growth. Atypical pneumonia screening, TB work up, connective tissue disease screening, viral screening, and thyroid function test were negative. Leptospirosis Ig M and microscopic agglutination test (MAT) were strongly positive, with titre 1:800. He was given IV Tazocin but he still had spiking temperature, thus antibiotic was escalated to IV Meropenam. His condition improved during ward stay. He was discharged with penicillin V and showed improvement during our clinic follow up. Leptospirosis IGM postive in the patient Positive microagglutination test in the patient Pleural and pericardial effusion Conclusions: Exudative polyserositis may be a real though uncommon manifestation of leptospirosis, seen in our patient. Hence we should have a high degree of suspicion to test for leptospirosis. Early diagnosis has to be made so that prompt management can be instituted to prevent mortality and morbidity. Background and Aims Introduction: Disseminated tuberculosis (TB) comprises of two or more noncontiguous sites resulting from lymphohematogenous dissemination of Mycobacterium tuberculosis. Case Report: We present a case of 47 year old Malay lady, known case of diabetes mellitus, hypertension, bronchial asthma and end stage renal failure on regular dialysis presented with cough for 2 months, loss of weight and appetite. She was admitted to medical ward and treated as pneumonia. Chest x-ray showed bilateral reticulonodular opacities. Broad spectrum antibiotics were administered and escalated to tazosin as patient had spiking temperature and dyspnea. She was noted to have vague central abdominal mass and systolic murmur over mitral region. Case was referred to surgical team and proceded with ultrasonography of abdomen and computer tomography of abdomen which showed omental mass and loculated ascites. Oesophagoduedenoscope showed antral gastritis and during colonoscope, surgical team was unable to advance the scope beyond 40 cm due to external compression. She was planned for CT guided biopsy but abandoned due to high risk of procedure. Echo showed right atrial mass with pericardial effusion over posterior wall. A possible diagnosis of atrial myxoma was given. Sputum AFB was negative. The patient was then referred to pulmonology team for bronchoscope and gene expert test. Upon reviewed by pulmonolgy team, patient was treated empirically as disseminated tuberculosis and scheduled for bronchoscopy. Patient showed remarkable improvement after day 7 of anti-TB medications. Her fever subsided and she appeared less tachypnoeic. Gene expert study came back as positive. CT abdomen and echo that was repeated after 2 weeks of antiTB medication showed reduction in the mass respectively. Conclusions: This case illustrates the importance of interventional pulmonology and high index suspicion to treat disseminated tuberculosis which can mimic other diseases. Background and Aims: To investigate the clinical significance of hypersensitive C-reactive protein,fribriogen and D-dimmer in the patients with connective tissue disease related interstitial lung disease(CTD-ILD). Methods: 69 patients with interstitial lung disease admitted (from January,2010 to April, 2016 in Zhujiang Hospital of Southen Medical University were included in the research. 29 patients were classified in the CTD-ILD group and 40 patients were classified in the non-connective-tissue-disease-related intersitial lung disease(NCTD-ILD) group. Also 25 healthy people were included as the control group. Hypersensitive Creactive protein(hs-CRP),fribriogen(Fg) and D-dimmer(D-DI) were analyzed. Results: The level of hs-CRP,Fg and DDI of CTD-ILD and NCTD-ILD groups were significantly higher than the control group. The level of hs-CRP of the CTD-ILD group was significantly higher than the NCTD-ILD group, while the difference of Fg and DDI level between 2 groups were not significant. Conclusions: Hs-CRP,Fg and D-DI show great value for the clinical diagnosis of CTD,the obviously high level of hs-CRP is correlated to the CTD. Background and Aims: Mycobacterium Tuberculosis infection influenced by genetic and environmental factor. Vitamin D deficiency and genetic variants on vitamin D receptor (VDR) gene have been reported to associate with pulmonary Tuberculosis (TB). This Study investigate the interaction between vitamin D serum concentration and vitamin D receptor gene BSMI polymorphism on pulmonary TB. Methods: We conducted a case-control study using 60 pulmonary TB patiens as a case and 60 healthy control. Vitamin D level were measured for all participant. Vitamin D receptor gene BsmI polymorphism was perfomed by PCR-RFLP. The corelation between vitamin D level and vitamin D receptor gene BsmI polymorphism on pulmonary TB were statistical analyzed. Results: The frequencies of vitamin D level were sufficient 38.3%, insufficient 43.3%, deficient 18.3% for pulmonary TB patients and sufficient 11.6%, insufficient 50%, deficient 38.3% for healthy control. There was a significant association between vitamin D levels and pulmonary TB (OR 0.14, 95% CI: 0.04-0.44 for deficient vs sufficient). There was no association between vitamin D levels and pulmonary TB (OR 0.55, 95% CI: 0,22-1.34 for deficient vs insufficient). The frequencies of BsmI genotypes were BB 18.3%, bb 21.6%, Bb 60% for pulmonary TB patients and BB 16.6%, bb 11.6%, Bb 71.6% for healthy control. There was no significant association between vitamin D receptor gene BsmI polymorphism and pulmonary TB (OR 0.59, 95% CI: 0.16-2.08) for BB vs bb. There was also no significant association between vitamin D receptor gene BsmI polymorphism and pulmonary TB (OR 0.45, 95% CI: 0.16-1.25) for Bb vs bb. Conclusions: There was a significant association between vitamin D levels and pulmonary TB but no significant association between vitamin D receptor gene BsmI polymorphism and pulmonary TB. Background and Aims: Prosthetic joint infection is a serious complication of prosthetic arthroplasty. Common etiologic agents are coagulase negative Staphylococcus, Staphylococcus aureus, gram negative bacilli, and anaerobes. Mycobacterium tuberculosis (MTB) infection of prosthetic joint is rare, and its atypical manifestation may delay the diagnosis and resulting in poor clinical outcome. Methods: A 70-year-old man was referred to Siriraj Hospital because of fever along with left knee pain and swelling for 2 months. His underlying disease are nasopharyngeal carcinoma which treated by concurrent chemoradiation, papillary thyroid carcinoma status post total thyroidectomy with I 131 ablation, and bilateral osteoarthritis of both knee with total knee arthroplasty 8 years ago. Results: Physical examination revealed erythematous, swelling, and warmth of left knee with limit range of motion. Laboratory findings showed peripheral WBC count of 20,700 cells/mm3 with 87 % PMN. CXR revealed military nodules corresponded to prior follow-up chest CT scan 2 months earlier for monitoring his thyroid cancer. Arthrocentesis of left knee yielded turbid joint fluid with WBC of 188,000 cells/mm3 with 94% PMN, and 6% lymphocytes. The gram stain demonstrated no organisms and the staining for AFB was positive. Subsequent molecular studies revealed MTB DNA without mutation conferring rifampicin resistance. Subsequent culture was positive for MTB 4 weeks later. Anti-tuberculosis drugs consisted of isoniazid, rifampicin, pyrazinamide, and moxifloxacin were prescribed along with prosthetic joint removal. The patient remains well at the 2-month follow-up visit. Conclusions: Tuberculous infection of prosthetic joint is an uncommon complication in medium to high TB burden country as Thailand. Its clinical presentation mimics usual septic arthritis and can confuse physicians. Definite diagnosis was usually verified by joint fluid and/or synovial or joint tissue cultures or tissue histopathology. Most of the patients also have concomitant pulmonary tuberculosis as a primary source of hematogenous spreading to the joint. Background and Aims: Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis (M.tb) and become the primary cause of death. Cytokine in tuberculous pleural effusion i.eTNF-a, is produced by Th1 cells and act as the primary inflammatory mediator in local reaction to form granuloma in pleura. Mycobacterial antigen interacts with previously sensitized T cells in pleura. This process will stimulate delayed type hypersensitivity reaction, causing caseating necrosis of granuloma that will affect pleural capillary permeability towards protein and leads to pleural effusion. The goal of this research is to compare the level of pleural fluid TNF-a in tuberculous and non tuberculous pleural effusion Methods: This is an experimental research with observational analysis cross sectional design that was held in Dr.Soetomo General Hospital Surabaya inpatient unit. The subject is tuberculous and non tuberculous pleural effusion patients that meets inclusion and exclusion criteria. Total subject is 11 patients in tuberculous pleural effusion group and 11 patients in non tuberculous pleural effusion group Results: The results of this research shows that the level of pleural fluid TNF-a in tuberculous pleural effusion is higher compared to non tuberculous pleural effusion (25,43 AE 13,55 pg/mL vs 5,98 AE 1,89 pg/mL, p value 0,001 < 0,05) Conclusions: The level of pleural fluid TNF-a in tuberculous pleural effusion is higher compared to non tuberculous pleural effusion Background and Aims: Nowadays, tuberculosis and smoking become a major health problem in the world. Indonesia ranks as the second highest country in term of TB cases and ranked 4 th as country with the highest cigarettes consumption in the world. Exposure to smoking will increase the risk of infection, disease, recurrence and even death because of TB. -IFN-γ, secreted by Th1 cells is an important cytokine in the body's immune response against intracellular bacteria, e.g Mycobacterium tuberculosis. Various studies mentioned that exposure to cigarette smoke will reduce IFN-γ production through inhibition of macrophages and T cells function. This study's aim is to determine the relationship of smoking degree, assessed through Brinkman index, with sputum IFN-γ levels in smear-positive pulmonary TB patients. Methods: We conducted a cross sectional observational analysis study design in outpatients with smear-positive pulmonary TB at Dr. Soetomo Hospital. Early morning spontaneous sputum was obtained from samples to determine IFN-γ levels. Smoking degree was calculated by multiplying the number of cigarettes smoked per day and smoking duration (year). Relationships of sputum IFN-γ level and smoking degree of subjects were analyzed by Pearson or Spearman correlation test in accordance with the scale of data existing. Results: There was no significant relationship between IFN-γ sputum level and smoking degree in smear positive pulmonary TB patients (p = 0.519). Obtained mean levels of IFN-γ sputum was 417.739 AE 196.168 pg/ml and the mean of Brinkman index was amounted to 383.28 AE 364.170. Conclusions: There was no significant correlation between IFN-γ sputum level and smoking degree in smear positive pulmonary TB patients. Background and Aims Background: Chronic obstructive pulmonary disease (COPD) and asthma are the important lower obstructive airway diseases. The spirometry is the gold standard for diagnosis of COPD and supports the diagnosis of asthma, however, patients with physical and mental limitations may not meet an acceptable criteria of the FVC maneuvers. The impulse oscillometry (IOS) which measures the resistance (R) and reactance (X) of the respiratory system and requires the minimal patient effort may be an alternative to the spirometry for diagnosis and category the obstructive pulmonary disorders. Aims: To determine the correlation between FEV1/FVC and FEV1 and IOS parameters (R5, R20, R5-R20, X5, Ax and Fres) in patients with lower airway obstruction. Methods: Cross-sectional study was conducted to evaluate the correlation between the IOS and the spirometry in patients diagnosed either COPD or asthma which FEV1/FVC < 70%. Of 171 patients (100 patients with COPD and 71 patients with asthma) who performed both the spirometry and the IOS were enrolled in the study. Results: R20, R5-R20, X5, AX and Fres, except R5 were all significantly associated with FEV1/FVC (p < 0.01) in patients with lower obstructive airway diseases. The highest correlation was between Fres and FEV1/ FVC (%) (r = -0312). However degree of airway obstruction as expressed in FEV1 % predicted was more correlated than FEV/FVC. The highest correlation was between Ax and FEV1 % predicted (r = -0.575). Conclusions: Area of reactance (AX) from impulse oscillometry system (IOS) was the most correlation with FEV1% predicted in patients with lower airway obstruction. Background and Aims: Although cryotherapy has been shown to be effective in managing advanced malignant bronchial tumours in adults, there is very little in the literature describing its use in pediatric airway diseases. To observe the short term effect of cryotherapy via flexible bronchoscopy for treatment of various Bronchial problem in children. Methods: I performed flexible bronchoscopic using nitrous oxide-driven cryoprobe to manage airway diseases such as foreign bodies,granulation tissues,bronchial masses removal,repair of subglottic stenosis, and transebronchial lung biopsies (TBLB) of 20 children who ranged in age from 11 months to 5 years and analyzed outcomes and complications. Results: In a period of 6 months, cryotherapy was performed under light sedation with inhaled Lidocaine and low doses of Propofol using fibroptic bronchoscope.The indication for cryotherapy were foreign bodies(5 case),granulation tissues(6 case),bronchial mass removal (2 case),repair of subglottic stenosis(3 case), and transebronchial lung biopsies (4 case). The only complication regarding cryotherapy was mild bleeding in 3 case that manage with using local epinephrine and balloon dilatation. Conclusions: Cryotherapy via flexible bronchoscope is an effective method to treat trachobronchial diseases of children. Background and Aims: Large scale epidemiological data of pleural fluid characteristics are lacking. We are an established pleural centre 1 with high rates of pleural malignancy in the North East of England. We aim to follow the British Thoracic Guidelines 2 and sought to add to the body of evidence. Methods: All pleural aspirations done between January 1 st 2014 and December 31 st 2015 were analysed for fluid biochemistry, microbiology and cytology and final diagnoses. We classified a exudate as a fluid protein >34 g/L or a fluid LDH 200 IU/L. We did not utilise Light's criteria as serum characteristics were not collected in the data. Results: We included 264 patients in the study with an average age of 74 years. Of the 264, 44 (17%) had a final diagnosis of a primary lung cancer. Each patient's cytology was analysed, and 26 patients (59%) has positive pleural fluid cytology on the first aspiration. 15 patients had a further aspiration, and only 6 (14%) had further diagnostic benefit. In addition, 4 patients (9%) had a transudative pleural effusion. On review of patients with an empyema (n = 16), only 2 (13%) had positive microbiology. 12/14 (86%) had a pH <7.21, as two patients did not have a pH sent. 100% of these patients had an exudate. In regards to following BTS guidelines 2 , 136 (52%) of pleural aspirations did not meet current BTS guidelines that every pleural aspirate should be sent for pH, microbiology, cytology, protein, LDH and glucose. The most commonly missed investigation was glucose on 81 occasions. Conclusions: Our findings are consistent with current literature in regards to transudates in lung cancer. Our trust should do more to improve microbiological yield in suspected empyemas, and encourage a contemporaneous blood LDH and protein on all patients. For this, we suggest using blood culture bottles in addition to universal containers. Background and Aims: Thoracoscopic biopsy under local anesthesia has been reported to be an effective method for the diagnosis of pleural diseases. Full-thickness biopsy specimens are required, especially in mesothelioma, and an insulated-tip diathermic knife (IT knife) was proposed as a useful device. We devised a new, simplified technique, the pre-cut method using injection needle, to obtain sufficiently-sized tissue specimens for pleural biopsy. Methods: Thoracoscopic pleural biopsy was performed under local anesthesia for undiagnosed, exudative pleural effusion, and the pre-cut method using injection needle was applied in two patients. The procedure was performed as follows: 1) an injection needle (23G, 4 mm length) was inserted into the pleura around the lesion through a semi-flexible thoracoscope (LTF type 260; Olympus); 2) while injecting 1% lidocaine with epinephrine and lifting the pleura from fascia, the needle was positioned to make an incision in the pleura; 3) three pre-cut incision lines were arranged in a triangle; 4) closed biopsy forceps were inserted at the precut incision line, and the forceps were opened to peel the pleura from fascia; 5) after replicating this maneuver along the triangular incision, one side of the triangle was grasped by the forceps, and the specimen was peeled from the parietal pleura. Results: Case 1 A 76-year-old male with right pleural thickening and effusion. The pre-cut method permitted the diagnosis of biphasic mesothelioma.Case 2: A 72-year-old male with left pleural effusion. Acid-fast staining and polymerase chain reaction analysis of pleural effusion were negative for acid-fast bacilli. Using histopathology and tissue culture findings, the pre-cut method permitted the diagnosis of tuberculosis. Conclusions: The pre-cut method using injection needle was an effective technique to obtain sufficiently-sized specimens for pleural biopsy, without specialized apparatus. Background and Aims: Nasotracheal intubation can be very useful technique for dental, orofacial surgery. But anatomical variation of nasal cavity is common in patients, so sometimes nasotracheal intubation without thorough understanding of anatomy of nasal cavity can be difficult to approach and create several complications. This case presents nasotracheal tube obstruction due to total middle turbinectomy during nasotracheal intubation Methods: 19-yr-old male was scheduled for left mandibular angle and orbital wall fracture. Nasotracheal intubation was needed during surgery. Before induction, anesthesiologist asked which nostril was more comfortable to breathe when the other occluded. He felt more comfortable with right nostril, so anesthesiologist decided to put the tube in right nostril. Induction was performed with bolus injection of propofol and rocuronium and continuous infusion of remifentanil. After mask ventilation, anesthesiologist intubated the patient. After intubation, the patient was not ventilated well, and decreased breathing sound and abrupt increased inspiratory pressure were observed. The anesthesiologist extubated the tube immediately and we found nasotracheal tube obstruction with turbinate. Nasotracheal intubation was performed again in right nostril to stop epistaxis with compression effect, the surgery was performed with no problem. After the surgery, we consulted otolaryngologist. Facial CT was examined again, and we found out the patient had severe nasal septal deviation to right side, and total middle turbinectomy was done with nasotracheal intubation. But the patient got discharged with no complication. Conclusions: Careful assessment should be performed before nasotracheal intubation to avoid complication. Several methods are performed to decide which nostril we should use to perform intubation. Breathing with one nostril is one of the method, but it cannot be perfect to avoid complication. Septal deviation and clinical symptom can't get matched. We suggest anterior rhinoscopy before nasotracheal intubation if the patient was not fully evaluated with facial CT Background and Aims: Epithelioma is uncommon, and has been reported to occur in the soft tissue, salivary glands, fort, and lungs; however, occurrences in the bone are very rare, with only 13 cases reported worldwide. Moreover, there have been no cases reported in pediatric ribs. Methods: Here, we report the case of a 13-year-old female with epithelioma of the rib, who was referred to the hospital for pain in the left side of her chest. It was particularly painful when she was playing the saxophone. An X-ray showed an abnormal shadow on the 7th rib, the MRI showed a contrasting lesion on the 7th rib, and the CT showed bone destruction and sclerosis inside the lesion. It was difficult to determine whether the lesion was malignant or benign, so an incisional biopsy was performed. Results: The pathology results showed that the cytokeratin, AE1/AE3, α SMA, desmin, and S-100 were positive, suggesting epithelioma; therefore, a costal segmental en bloc resection was performed to remove this tumor. After the operation, the patient's sharp pain was relieved. Conclusions: Rib tumors make up approximately 5% all of bone tumors, and are relatively rare. Representative benign cases include osteochondroma, enchondroma, fibrous bone dysplasia, and acidophile-related granulomatous disease; while the malignant cases include bone metastasis, chondrosarcoma, osteosarcoma, isolated plasma cell tumors, and Ewing's sarcoma. It is frequently misdiagnosed before surgery, so it has been suggested that a wide local excision be performed for all costal tumors. In this case, the patient had epithelioma occurring in the bone, showing that it is important to consider a rib lesion in a patient presenting with chest pain. Background and Aims: Tunnelled indwelling pleural catheter (TIPC) has been utilised as an effective alternative in the palliative management of malignant pleural effusions. Its application in benign refractory pleural effusions is now rapidly growing, with expanding evidence in conditions such as hepatic hydrothorax and cardiac failure. Benign chylothorax is another condition for which TIPC may offer an effective symptom management, particularly when surgical or interventional radiological procedures are not suitable. Nevertheless, repeated drainage of protein-rich chyle raises the concern of severe nutritional deficiency, and caution must be exercised. Methods: We report a case of benign chylothorax managed successfully and safely with TIPC. Results: An 85-year-old previously-independent, Caucasian female presented with 3 months of worsening dyspnoea and was found to have a left-sided unilateral pleural effusion. Background co-morbidities included ischaemic cardiomyopathy, benign multinodular goitre, atrial fibrillation, type 2 diabetes, dyslipidaemia and gout. There was no history of malignancy. She was a never-smoker and did not drink alcohol. Echocardiogram confirmed stable left ventricular function. Thoracocentesis revealed a chylothorax (Triglyceride >15.1 mmol/L) and significant symptomatic improvement was noted. Pleural fluid examination excluded malignant and infective causes. CT chest demonstrated a large multinodular goitre with significant mass effect on the superior thoracic outlet. The left internal jugular and subclavian veins were displaced, and the thoracic duct was likely compressed. Thyroid function was normal. Surgery was recommended as the preferred management, with radio-active iodine therapy as an alternative. These were however refused by the patient. TIPC was then inserted due to rapid reaccumulation of the chylothorax. The patient reported stable and effective symptom relief 4 months after insertion with a 3-weekly intermittent drainage regime. There has been no development of protein deficiency with good dietician liaison and supplementation. Conclusions: TIPC offers a safe and effective option in the palliative management of benign chylothorax, though attentive monitoring of the nutritional status is essential. Background and Aims: Chronic obstructive pulmonary disease known as chronic inflammatory disease that do not occur locally in the lung but also a systemic effect, including peripheral muscle weakness and increased lactic acid. Ubiquinone contained in the mitochondria and plays an important role in aerobic energy production and also have antioxidant effects. Giving ubiquinone expected to improve the 6 MWT and lower lactic acid levels in patients with COPD Methods: This study is an experimental study with double-blind randomized controlled. The subjects of this study are patients with stable COPD category B and D which at the outpatient Pulmonary clinic of Dr. Soetomo Hospital and meet the inclusion and exclusion criteria. Patients who meet the selection criteria are divided into 2 groups, ubiquinone and placebo for 8 weeks and patients continue to use drugs regularly. All patients measured blood levels of lactic acid, the 6-minute walk test, spirometry before and after administration of ubiquinone or placebo. A total 32 subjects were divided into 16 patients in ubiquinone groups and 16 patients in control groups Results: There were no significant differences between the two groups in gender, degree of COPD and BMI. Lactic acid levels in the treatment group decreased significantly compared with the control (4.619 AE 0.429 to be 3.131 AE 0.583 in ubiquinone group, 4.544 AE 0.383 to be 4.675 AE 0.409 in control group; p <0.017). Pulmonary function tests were not statistically significant in both groups. On the 6-minute walking distance increased in the treatment group compared with the control group (296,81 AE 61,123 to be 354,38 AE 53,131 in ubiquinone group and 329,06 AE 53,610 to be 319,06 AE 44,990 in control group;p < 0.014). Conclusions: Ubiquinone administration has favorable effect on the energy production of muscle and lower lactic acid levels in patients with stable COPD category B and D. Background and Aims: Cigarette smoking causes small airway obstruction (SAO) and is the harbinger of developing chronic obstructive pulmonary disease (COPD). The reduction in FEF 25-75% associated with chronic cigarette smoking can be explained by loss of lung elastic recoil pressure which reduces the force driving air out of the lung. Therefore early detection of pulmonary function tests will prevent the risk of airway disease The aim of the present study is to analyze pulmonary function changes, FEF 25-75% in smoking and to compare them with healthy non smokers Methods: In this study 96 healthy male and female subjects, their age ranging from 30-70 years, 48 smokers and 48 nonsmokers were assessed for their pulmonary function tests by using a spirometer. Results: Study showed that impact of cigarette smoking on pulmonary function in smokers had a significantly greater percentage decline in the FEF 25-75%, ratio than non-smokers (p < 0,05), they suggested that smokers develop changes in pulmonary function indicating early peripheral airway narrowing. There were significant correlation between smoking duration and rate of values FEF 25-75%. We found a dose-response relation between smoking and FEF 25-75% . Duration and amount of smoking were associated reduction in FEF 25-75% . Conclusions: Smokers had a significantly greater percentage decline in the FEF 25-75% than non-smokers. There were significant correlation between smoking duration and rate of values FEF 25-75%. The deterioration of lung functions related to the number of cigarettes smoked per day in smokers. Background and Aims: The loss of airway epithelial integrity contributes significantly to asthma pathogenesis. Recent reports reveal that Thymic stromal lymphopoietin(TSLP) may have dual immunoregulatory roles. TSLP is present in 2 isoforms, including short and long TSLP. In inflammatory disorders of the bowel,the long-form TSLP(lTSLP) promotes inflammation and the short form of TSLP(sfTSLP) inhibits inflammation. We hypothesize synthetic sfTSLP preventsairway epithelial barrier disruption induced by House Dust Mite(HDM). Methods: Normal human bronchial epithelial cells(16HBE) were stimulated with HDM and 1α,25-Dihydroxyvitamin D3. We evaluated the expression of TSLPs by quantitative real-time PCR and Western blot. Meanwhile, transepithelial electrical resistance (TEER) and fluorescentdextran (FITC-dextran) permeability and distribution of E-cadherin and β-catenin were assessed to evaluate the airway epithelial barrier function. In vivo, BALB/c mice were exposed to HDM by nasal inhalation to set up asthma model in 5 consecutive days per week, sfTSLP and 1α,25-Dihydroxyvitamin D3 were inhaled 1 hour before HDM inhalation. 8 weeks latter, we utilized animal lung function test and pathological staining to evaluate the asthma situation. Results: In vitro, 1α,25-Dihydroxyvitamin D3 upregulated sfTSLP expression and inhibited HDM-dependent upregulation of lTSLP. Using sfTSLP and 1α,25-Dihydroxyvitamin D3 could prevent HDM-induced airway epithelial barrier disruption. Asthmatic mice model was successfully to be established, as inflammatory factors like IL-4、IL-5 and lTSLP in BALF were unregulated in consistent with serum IgE except IFN-γ. Airway epithelial junction proteins was partially lost or dislocated. Moreover, Synthetic sfTSLP and 1α,25-Dihydroxyvitamin D3 ameliorated HDM-induced asthma in mice. Conclusions: The two isoforms, short and long TSLP have a different expression and different biological properties. We emphasize the importance of analyzing the two TSLP isoforms separately. Moreover, our results indicates that sfTSLP and 1α,25-Dihydroxyvitamin D3 may be a novel therapeutic strategy for individualized treatment of asthma. Background and Aims: Accidental inhalation of both organic and nonorganic foreign bodies continues to be a leading cause of childhood morbidity and mortality, requiring prompt diagnosis and early management to minimize the risk of serious and sometimes fatal consequences. Each case of foreign body aspiration has a different face. The variables involved include type of object, reaction to the aspiration, and location. The physical characteristics of the object, the clinical presentation, and the expertise of the Bronchoscopist will frequently determine the ultimate outcome. Methods: All of the patients underwent Flexible Fibroptic Bronchoscopy procedures done in our Pediatrics Bronchoscopy suite by introducing light sedation with low doses of Propofol and extraction was done by many types of forceps, baskets, Balloons, electrocutery knifes and cryoprobs. Results: After doing Flexible Fibroptic Bronchoscopy with new methods in more than hundreds cases of Aspirated foreign bodies covering a range of about 7 month to 15 years the success rate were 100% with no any major complication. Conclusions: In an expert hands with well equipped facilities, Flexible Fibroptic Bronchoscopy is the "gold standard" for the diagnosis of pediatric airway foreign bodies and is the preferred instrument for its management. Background and Aims: To discuss the value of medical thoracoscopy in pleural disease diagnosis and treatment of children Methods: retrospectively analyzed the clinical characteristics and outcome of the 15 children cases with refractory pleural lesions who had been diagnosed and treated by medical thoracoscopy in our hospital from January 2010 to February 201. Results: Average age of these 15 cases(male in 11 cases, female 4 cases) was 4.8 years old (ranging from 1 to 15), lesions of 10 cases located in the left pleural cavity, 5 in the right. All cases are in the acute phase within 2 weeks. 2. Before performance of the medical thoracoscopy, 3 cases considered streptococcus pneumoniae, 1 considered staphylococcus aureus infection, 1 considered Tuberculous pleurisy. 10 cases were unknown. After the medical thoracoscopy, we made conculsion that the causes of 3 cases were streptococcus pneumonia, 1 was staphylococcus aureus infection, 4 were tuberculous pleurisy, 1 was mycoplasma infection, 1 was chest foreign body, pathogens of another 5 were still unknown. Before medical thoracoscopy, loculated pleural effusion or atelectasis by compression were still there of all cases even after thoracic drainage and pleural lavage by saline and urokinase. After the medical thoracoscopy, lung recruitment was found in all cases Conclusions: 1)Medical thoracoscopy is a minimally invasive surgical treament of pediatric pyothorax, which can promote lung recruitment by drainage and lavage under direct vision, and clearing pus moss, parcels and adhesions at the same time. 2)Some children with pleurisy of unknown causes, can confirm the diagnosis by pleural biopsy.3)Some wooden bronchus foreign bodies can be moved to the distal airway even wear out pleura into the pleural cavity as breath, the conventional treatment cannot solve the problem, but the medical thoracoscopy may effect Background and Aims: To report a rare case of foreign body in thoracic cavity Methods: retrospectively analyzed the clinical characteristics and process of the case of foreign body in thoracic cavity Results: A two-year-old male was admitted to our hospital because of fever and cough for 10 days. History of a foreign body inhalation was uneventful. A Computerized Tomography(CT) scan showed right lower lung infection, and right pleural effusion. He was subsequently treated with antibiotics. Temperature returned to normal while the frequency of cough increased. he was performed a bronchoscopy revealed wooden foreign body on the right side of the basal segment. and failed to remove the whole foreign body. He appeared repeatedly high fever postoperative and was hyperpyrexia, tachypnea with a rate of 75/minute, mild inspiration three concave and bad spirit. he was immediately to the CPAP machine auxiliary ventilation. On the eighth day after admission, he was performed a flexible bronchoscope used as a thoracoscope under the general anesthesia. The bronchoscope found that foreign body puncture lung pleura to the chest (FIGURE 4.), hence the foreign body which was a dog's tail grass about 4.5 cm was directly taken out. The boy was inhaled high oxygen flow after removal of the foreign body, and continued to complete the thoracic cavity closed drainage when the blood oxygen saturation can remain above 90%. Temperature returned to normal after 2 days. A CT scan showed lung compression tissue was less than 20%, compared with the previous improved significantly. The boy was continued the anti-infect treatment and discharged from the hospital. Growth and development was good by a follow-up telephone call and the Computerized Tomography scan revealed the lesions was fundamental absorption Conclusions: Wooden foreign body maybe move to thoracic cavity, and Thoracoscopy should be considered early in these patients in case of refractory pleural effusion and pneumothorax The results were compared with that of direct immune-fluorescence assay and the samples with inconsistent results by the two methods were verified by RT-PCR Results: The results indicated that influenza virus antigen detection by Sofia influenza A + B FIA was highly consistent with the results of direct immune-fluorescence assay.The sensitivity and specificity for detecting influenza virus A were 100% and 96.53%,the specificity raised to 99.6% after verified by RT-PCR because 16 of 18 inconsistent samples were positive by RT-PCR. For influenza B the sensitivity and specificity were 97.83% and 97.04%,and raised to 98.4% and 99.8% after verified by RT-PCR with 15 of 17 inconsistent samples were positive by RT-PCR. Compared with influenza virus B, more children were infected with influenza virus A that course more serious clinical symptom Conclusions: Influenza is a significant cause of children respiratory infections.Sofia Influenza A + B FIA is a rapid and easy antigen-detecting assay for influenza virus A and B, which has high concordance rate with direct immune-fluorescence assay that can be used for screening and diagnosis of influenza virus A and B Background and Aims: Chrysin, a member of flavonoid family, has been shown the capacity of anti-inflammation property. Autophagy has been considered as a key role in the inflammatory response. We try to investigate the effects of the novel chrysin on LPS-induced ARDS and to determine whether autophagy is invovled. Methods: BALB/c mice aged 6-8 weeks were randomly divided into 7 groups: 3 control groups receiving saline, chrysin (100mg/kg) or LPS (50 μM); 2 groups receiving chrysin (50mg/kg) or chrysin (100mg/kg), followed by LPS; a group receiving the autophagy antagonist 3-MA; and a group receiving 3-MA, then chrysin (100mg/kg), finally LPS. LPS and saline were injected intratracheally. Chrysin was injected intraperitoneally 30 min before LPS, while 3-MA was injected intraperitoneally 30 min before chrysin. Mice were killed at 6, 12 and 24 h. Samples of BALF and lung tissues were collected for analysis. Results: All 3 time points, groups receiving either dose of chrysin followed by LPS had significantly lower total cell counts and levels of TNF-α and IL-6 in BALF than did the group given only LPS. At 24 H, the western blot showed the LC3b levels of 2 chrysin groups were about 1.4-fold and 1.8-fold high of the LPS group, and the NF-κB passway were significantly restrained. Chrysin activated the autophagy by increasing LC3b level in a dose-dependent manner. The autophagy inhibitor 3-MA partially reversed chrysin-induced LC3b elevation and NFκB passway suppression. Conclusions: These results suggest that chrysin may attenuate the lung inflammation of LPS-induced ARDS by activating autophagy, and the autophagy may be deeply involved in the NFκB-dependent ARDS inflammatory response. Baker's asthma Baker's allergy and asthma-a review of literature Baker's asthma SERUM BENZO(A)PYRENE DIOLEPOXIDE (BPDE) LEVEL IN KRETEK CIGARETTE SMOKERS : A PRELIMINARY STUDY Methods: For efficacy and safety analysis, data from the Chinese cohort (n = 595), comprising 80% patients of the 26-week LANTERN study were compared with data from the 26-week ILLUMINATE study (n = 522; 89% of Caucasian patients) with moderate-to-severe COPD. For pharmacokinetic evaluation, the area under the plasma drug concentration-time curve from 0 to 24 h (AUC 0-24h,ss ) and peak plasma concentration (C max,ss ) of IND and GLY at steady state following repeated daily administration for 14 days were compared between the two populations. Comparisons were not based on any formal statistical analyses. Results: The mean baseline post-bronchodilator FEV 1 (% predicted) in the Chinese and Caucasian population were 51.3 (LANTERN) and 60.2 (ILLUMINATE), respectively. IND/GLY provided significant improvement in trough FEV 1 versus SFC at Week 26 in both Chinese (LANTERN IND/GLY significantly reduced the rate of moderate or severe exacerbations (LANTERN; rate ratio [RR], 0.57; p = 0.015), while in Caucasian patients, this rate reduction was numerically lower versus SFC (ILLUMINATE; RR, 0.80; p = 0.512). The comparison of the systemic exposure data AUC 0-24h,ss and C max,ss following repeated daily administration of IND/GLY 110/50 μg did not indicate any clinically relevant differences between the two populations. In terms of adverse events, the safety profiles were similar between the two populations. Conclusions: Once-daily IND/GLY demonstrated greater efficacy versus salmeterol/fluticasone combination IND/GLY) WITH OTHER COMBINATIONS OF INHALED MAINTENANCE THERAPIES FOR COPD: THE LUMIERE STUDY DESIGN Medical Primary Care the most common HRCT pattern in IPF, and NSIP on chest high-resolution computed tomography (HRCT) and other serum markers are not well understood. Our aim is to investigate the association between HRCT results and serum marker levels, bronchoalveolar lavage (BAL) fluid analysis, and pulmonary function testing (PFT) results. Methods: We evaluated serum marker levels (KL-6 Conclusions: These findings suggest that chest HRCT results are significantly associated with SP-D levels, lymphocytes in BAL fluid, FVC, and DLCO at diagnosis We assumed that drainage volume from Water Sealed Drainage (WSD) has a correlation with REPE. Aim: To find out the correlation between drainage volume of pleural fluid in patient with massive hemorraghic pleural effusion with REPE's prevalence. Methods: This study used cross-sectional method. Samples were patients with pleural effusion, WSD-treated, had chest x-ray and did not have heart and kidney disorder nor existing pulmonary edema. The data came from 80 patients' medical records. The collected data were sample's characteristic, 1 st hour and first 24-hour drainage volume of pleural fluid from WSD, clinical and radiologic REPE. Mann-Whitney test, Independent-t-test and bi-series correlation test were used for statistical analysis. Results: The study found 10(12,5%) patients had clinical REPE, 14(17,5%) patients had radiologic REPE, 4(5%) patients had clinical and radiological REPE, and 20(25%) patients had clinical or radiological REPE. There was no significant different of 1 st hour volume between positive and negative results of REPE(p = 0,05 Conclusions: There is a significant correlation in low and moderate level between first 24-hour drainage volume of pleural fluid and REPE Diesel exhaust particle (DEP) is the major components of PM2.5, and much attention has focused on PM2.5 in relation to many pulmonary diseases. Studies of molecular mechanisms have focused on the role of reactive oxygen species (ROS) generated directly and indirectly by exposure to DEP. The current study was designed to explore the role of DEP whether or not induce EMT process in airway epithelial cells by oxidative stress. Methods: We used human bronchial epithelial cell (HBEC) line BET-1A. In the first experiment, DEP (Standard Reference Material 2975) was treated culture cells with various concentrations for 24h. In the second experiment, different concentrations of N-acetylcysteine (NAC) were pretreated culture cells for 6h, and then DEP was treated with 25μg/ml for 24h. After DEP exposure, the cells were harvested to extract RNA and protein. The mRNA expression of antioxidant enzymes were determined by real-time RT-PCR, and protein expression of E-cadherin and Ncadherin were assayed by western blotting. We also examined the effect of DEP on cells migration by wound healing assay in HBEC cells. Results: E-cadherin expression was down-regulated and N-cadherin expression was up-regulated by DEP exposure in HBEC cells. The cells migration also was up-regulated by DEP exposure. The changes of expressions of E-cadherin, N-cadherin, and cells migration by DEP exposure were blocked by NAC pretreatment. HO-1, NQO-1 mRNA expression was up RECURRENT PULMONARY INFILTRATES AND SEVERE ANEMIA IN A 23 MONTH OLD CHILD: A DIAGNOSTIC CHALLENGE The types of bias in our two cases were both common. Knowing the effects of bias in the diagnostic process should prove useful for debiasing. Background and Aims: Asthma remains a serious healthcare burden worldwide. This analysis aims to characterise asthma exacerbations requiring hospitalization in China and evaluate the healthcare costs. Methods: This multi-center retrospective study was conducted in 29 hospitals of different cities throughout China. In each hospital, all cases dated from Jan1, 2013 to Dec 31, 2014 were screened. Patients that met the following criteria were included: (1) aged ≧14 years; (2) hospitalized with asthma exacerbations; (3) had an asthma diagnosis for at least 3 months according to the GINA criteria. In case of including multiple hospitalizations of the same patient, the most recent incidence was included. Information about clinical characteristics and costs was extracted from the medical records and lists of expense. Results: Data from 3,240 asthmatic patients (1,369 males and 1,871 females) were analyzed. The average age was 56 years old. The proportion of patients with smoking history was 23%, while 9% were current smokers. During the previous year prior to the hospitalization, 35% were hospitalized with asthma exacerbations at least one time, and 21% visited the emergency department. Only 28% used asthma-controlling medicines regularly before the admission. The most common trigger for asthma exacerbations in this study was upper respiratory airway infection (41.82%). The average length of hospital stay was 9.33 AE 4.73 days. Of all patients, 2% were admitted to ICU and 2% were treated by mechanical ventilation. Ten patients died and the overall mortality was 0.31%. The average healthcare costs was 11,063.14RMB. The average drug costs was 6090.9RMB, counting for 55% of total health care costs. Conclusions: In this study, we demonstrated that only minority of the patients used asthma controllers regularly before the admissions with exacerbations. The mortality of hospitalized asthma patients in this study was 0.31%. The average hospital inpatient costs was much higher than the estimated yearly costs of maintenance therapy.Background and Aims: Tiotropium + olodaterol fixed-dose combination (T + O FDC) had shown superiority to either of the monotherapies in lung function, dyspnea, lung hyperinflation, and quality of life in COPD patients in several studies. The scientific interest related to patients' daily life, e.g. physical activity, has been growing. Although exercise capacity and daily physical activity improvement are mentioned as one of the important treatment targets in the Japanese COPD treatment guideline, these endpoints have not yet been evaluated in a large-scale randomized study in Japan. The VESUTO was planned to evaluate pharmacological intervention effects on these endpoints. Methods: The VESUTO is a randomized, double-blind, 2-way crossover, active-controlled study. A total of 180 COPD patients (GOLD stage 2-4) aged ≥40 years will be randomized in a 1:1 ratio to 1 of 2 sequential treatment groups, starting treatment with T + O FDC 5 μg/5 μg or tiotropium 5 μg, for 6 weeks in each treatment period. Both medications are orally inhaled once daily using RESPIMAT ® . The primary endpoint is inspiratory capacity (IC) at rest (60 minutes post-dose) after 6 weeks, for evaluating hyperinflation. Secondary endpoints are the 6-minute walk distance (6-MWD), for evaluating exercise capacity, and patients' daily physical activity measured using 3-axis accelerometer. A mixed-effects model repeated measures approach will be used to assess the primary and secondary endpoints. (NCT02629965) Results: The VESUTO initiated in February 2016 in Japan is currently recruiting patients. This is the first large-scale, randomized, double-blind, cross-over study to evaluate the efficacy of T + O FDC versus tiotropium not only on lung hyperinflation, but also on exercise capacity and physical activity in Japanese COPD patients. The VESUTO would provide further evidence of LAMA/LABA combination therapy for lung function, exercise capacity and physical activity associated with patients' daily life activity in Japanese patients with COPD. Figure: Study design V, visit; 6-MWT, 6-minute walk test; PFT, pulmonary function testing Conclusions Background and Aims: To evaluate the cost-effectiveness of the fixeddose indacaterol/glycopyrronium (IND/GLY) compared with tiotropium (TIO) and the fixed combination of salmeterol/fluticasone (SFC) in the management of COPD. Methods: A published and validated patient-level simulation model was adapted for use in Thailand to follow individual patients over a 3-, 5-, 10year and lifetime time horizons. Improvement in forced expiratory volume in 1 second (FEV1), exacerbation and pneumonia rate reduction was obtained by direct and indirect comparison of primary data from SHINE, SPARK and LANTERN clinical trials. Direct and indirect costs were obtained from published local studies and standard cost list. IND/GLY price proposed for national formulary listing was used, and other drug prices were those published by Ministry of Public Health, Thailand. All costs were expressed in USD 2016 values. Costs and outcomes were discounted by 3% annually. Univariate and probabilistic sensitivity analyses were performed on key input parameters. Results: IND/GLY yielded an incremental life year (LY) of 0.16 years and 0.12 additional quality-adjusted life years (QALY) over the lifetime when compared with TIO. In the comparison with SFC, IND/GLY increased 0.29 LYGs and 0.26 QALYs. The higher drug acquisition cost of IND/GLY was partially offset by lower costs of maintenance treatment, severe and non-severe exacerbation. Cost of treating pneumonia was reduced for IND/GLY vs. SFC. Considering the Thailand recommended threshold of 4,706 USD/QALY, IND/GLY was cost-effective with discounted incremental cost-effectiveness ratios (ICER) of 4,607 and 4,417 USD/QALY when compared with TIO and SFC, respectively. IND/GLY remained costeffective when indirect costs were excluded (healthcare provider perspective). The sensitivity analyses showed that results were robust to changes across scenarios. Conclusions: Based on the societal and healthcare provider perspectives, IND/GLY is likely to be cost-effective compared with TIO and SFC for a moderate-to-severe COPD population in Thailand.Background and Aims: The FLAME study was the first study to show superiority of IND/GLY (a LABA/LAMA) versus SFC (a LABA/ICS) in exacerbating patients with moderate-to-very severe COPD. 1 Here, we report the safety results from this study. Methods: FLAME was a 52-week, multicenter, double-blind study that randomized (1:1) patients with post-bronchodilator FEV 1 , % predicted, ≥25% to <60% and ≥1 exacerbations in the previous year to receive either IND/GLY 110/50 μg once daily or SFC 50/500 μg twice daily. Safety assessments included adverse events (AEs), serious adverse events (SAEs), cardiovascular safety, pneumonia (requiring documentation by radiographic imaging), and oral candidiasis (requiring positive fungal culture). Additionally, hypothalamic-pituitary-adrenal (HPA) axis function was determined by measuring 24-hour urine cortisol/creatinine ratio in a subset of patients. Results: Of the 3362 randomized patients, 3358 (IND/GLY, n = 1678; SFC, n = 1680) were included in the safety set. The overall incidence of AEs, SAEs and deaths was similar in both groups. In each group, the number of treatment-emergent deaths was identical (1.4%). The occurrence of adjudicated cardiovascular deaths (IND/GLY, 0.5%; SFC, 0.7%) was similar between the treatment groups. Incidence of pneumonia was significantly lower with IND/GLY versus SFC (3.2% versus 4.8%; p = 0.02). Additionally, the incidence of serious pneumonia was lower in IND/GLY group compared with SFC (2.0% versus 3.2%). Significantly more patients developed oral candidiasis (p < 0.001) in the SFC group (4.2%) compared with IND/GLY group (1.2%). The median percentage change in 24-hour urinary cortisol/creatinine ratio from baseline showed no change with IND/GLY (5.62%) but was significantly reduced by SFC (−10.39%, p = 0.018). Conclusions: Indacaterol/glycopyrronium showed a favorable safety profile, with less pneumonia and oral candidiasis incidence, compared with salmeterol/fluticasone. Unlike salmeterol/fluticasone, indacaterol/glycopyrronium treatment was not associated with suppression of HPA-axis function in exacerbating moderate-to-very severe COPD patients. Study was funded by Novartis Pharma AG Background and Aims: Effective management of COPD requires regular self-administration of inhaled medication. In COPD patients, inhalation effort required and flow rates achieved through DPIs, are some of the important considerations while selecting dry power inhalers (DPIs). We compared the peak inspiratory flow (PIF) rates achieved by COPD patients through three types of DPIs (Breezhaler ® , Ellipta ® and HandiHaler ® ). The effect of COPD severity on PIF rates was also assessed. This randomized, open-label, multicenter and cross-over study recruited patients with moderate-to-very severe COPD (GOLD 2014) aged ≥40 years with a smoking history of ≥10 pack years. No active drug or placebo was administered during the study. Inhalation flow profiles of patients were recorded using pressure tapped inhalers attached to a pressure transducer. For each patient, the inhalation profile with the highest PIF rate from three replicate inhalations per device was selected for analysis. The primary analysis was based on the per-protocol set comprising 93 patients who completed all three inhalations per device. A paired t-test was performed to compare PIF means between each combination of devices. Results: In total, 97 COPD patients were randomized, of whom 96 completed the study and 93 patients (per-protocol set) were included in the analysis. The highest mean PIF rate (L/min AE SE) was observed with the Breezhaler ® (107.5 AE 2.4), followed by the Ellipta ® (80.0 AE 2.2) and the HandiHaler ® (53.6 AE 2.1), across the moderate-to-very severe COPD patients. The mean PIF rate (L/min) achieved via the Breezhaler ® was highest vs the Ellipta ® (mean difference[Δ] = 27.7;p < 0.0001) and also vs the HandiHaler ® (Δ = 53.9;p < 0.0001). When assessed by COPD severity sub-groups, the Breezhaler ® device exhibited significantly higher PIF rate vs the Ellipta ® and vs the HandiHaler ® (Table) .Conclusions: COPD patients with varying degree of airflow limitation (moderate-to-very severe COPD) achieved the highest PIF rates via the Breezhaler ® compared with the Ellipta ® or the HandiHaler ® inhaler. Study funded by Novartis Pharma AG.Background and Aims: A previous study showed that N-acetylcysteine 600 mg bid reduces exacerbations in Chinese patients with moderate-tosevere COPD (Zheng JP, et al. Lancet Resp Med, 2014; 2:187-94) . Exacerbations were defined, according to Anthonisen criteria, as worsening symptoms with at least a 2 day persistence of two (type II) or all three (type III) major symptoms (worsening dyspnoea, increase in sputum purulence or volume), or of any one major symptom plus at least one minor symptom (type I) (upper airway infection, unexplained fever, increased wheezing) Methods: This is a post-hoc analysis of the same 1-year prospective, randomised, double-blind, placebo-controlled, parallel-group study, where 1006 patients, aged 40-80 years with moderate-to-severe COPD (postbronchodilator FEV 1 /FVC <0.7 and FEV 1 of 30-70% of predicted) were treated either with N-acetylcysteine (one 600 mg tablet, twice daily) or matched placebo for 1 year. We investigated whether N-acetylcysteine reduced the annual rate to moderate-severe exacerbation defined according to GOLD criteria, i.e. either episode treated with oral steroids/antibiotics (moderate) or hospitalized. This study was registered with the Chinese Clinical Trials Registry-ChiCTR-TRC-09000460 Results: Between June 2009 and December 2010, 1297 patients were screened, and 1006 were eligible for randomisation (504 to Nacetylcysteine and 502 to placebo). After 1 year, in N-acetylcysteine 216 patient with at least one moderate to severe exacerbation developed 349 moderate-severe exacerbations (0.816 exacerbations per patientyear), that was significantly lower than the 424 moderate to severe exacerbations that occurred in the 226 patients with at least one exacerbation (0.997 exacerbations per patient-year; rate ratio = 0.819 [p = 0.027]) in placebo group. N-acetylcysteine was well tolerated Conclusions: These results indicate that the long-term use of Nacetylcysteine 600 mg twice daily is associated with a reduction of exacerbations not only when defined on the basis of symptoms, according to Anthonisen criteria, but also when classified as moderate to severe according to the GOLD definition of exacerbation severity Background and Aims: GOLD 2016 strategy document suggests that the use of triple therapy improves lung function and quality of life and may further reduce exacerbations in patients with COPD compared to the mono or dual therapy. We assessed efficacy and safety of once-daily Tiotropium/Formoterol/Ciclesonide (TFC) (18/12/400 mcg) via DPI or MDI in patients with COPD in a real world setting. Methods: This 24 weeks, open-label, prospective, non-comparative, multi-centre, real world, observational study enrolled patients with COPD diagnosed as per GOLD 2014 requiring triple drug therapy as assessed by physician. The primary endpoint was mean change from baseline in pre-dose FEV 1 at week 24. FVC, CAT score, mMRC grade, treatment satisfaction and safety were also evaluated. Post-hoc analysis was done to evaluate the effects of TFC in smokers (S) and non-smokers (NS) with COPD. (Figure 1 ). At week 24, CAT score reduced significantly from baseline (Overall: -6.6 AE 6.09; S: -4.53 AE 7.17; NS: -8.06 AE 4.44; all p < 0.0001) ( Figure 2 ). Mean change in, pre-dose FEV 1 and FVC, CAT score and mMRC grade were significant across all visits. Majority of patients graded high satisfaction for triple therapy and were willing to continue it. TFC was well tolerated.Conclusions: TFC significantly improved lung function and symptoms in patients with COPD and was well tolerated, independent of their smoking history. Moreover, Non-smokers showed better improvements compared to smokers. Background and Aims: The oxidant/antioxidant imbalance is significantly pronounced in patients with COPD exacerbation. N-acetylcysteine (NAC) seems to have an influence in reducing COPD exacerbations via modulating the oxidative stress, but there are discordant findings on the actual anti-oxidant activity of NAC. We aimed to pharmacologically characterize the anti-oxidant effect of NAC in an ex vivo model of COPD exacerbation. Methods: The influence of NAC was assessed on the contractile response and anti-oxidant profile in human isolated bronchi incubated overnight with Krebs-Henseleit buffer solution (control) or lipopolysaccharide (LPS, 100 ng/ml) Results: LPS desensitized isolated airways against the transmural stimulation (-55% AE 13%, p < 0.05 vs. control). Concentrations of NAC ≥10μM restored the physiological contractile response in LPS stimulated bronchi (E max 99 AE 19% vs. control, p < 0.05 vs. LPS), whereas lower concentrations (<10μM) did not modulate this effect. Concentrations of NAC ≥1μM reduced the pro-oxidant response (peroxidase activity, hydrogen peroxide, malondialdehyde, nitric oxide: overall -31 AE 2%; p < 0.05 vs. LPS), and improved the anti-oxidant response (total anti-oxidant capacity, glutathione, superoxide dismutase: overall +97 AE 8%; p < 0.05 vs. LPS) induced by LPS. Lower concentrations of NAC (<1μM) did not modulate the bronchial oxidative imbalance (p > 0.05 vs. LPS) Conclusions: The results of this study demonstrated that concentrations of NAC >10μM are required to normalize the dysfunctional contractility of human bronchi and concentrations of NAC ≥1μM improve the oxidative imbalance in an ex vivo model of COPD exacerbation.Background and Aims: Randomized clinical trials (RCTs) form the basis of regulatory approval of new drugs and guidelines recommendations. However, RCTs often represent a small minority of the routine care population in which licensed drugs are prescribed, with a much more controlled ecology of care. Therefore, there is an increased need for additional information about effectiveness of treatments in broad populations managed according to usual clinical practice. LUMIERE is an international, prospective, 1-year observational cohort study to assess the real-world effectiveness of IND/GLY, and other inhaled combination therapies (ICT) for the treatment of COPD. Methods: Patients ≥40 years of age, with physician diagnosed COPD, a smoking history of ≥10 pack-years, and a new prescription of any ICT that include atleast 1 long-acting bronchodilator, are eligible for the study. The primary objectives are to assess the effectiveness of once-daily IND/GLY 110/50 μg on rate of moderate and severe exacerbations associated with COPD (EA-COPD), and on health status with the Clinical COPD Questionnaire (CCQ). The secondary objectives are to compare the effectiveness of IND/GLY versus other fixed or loose ICT on moderate/severe EA-COPD and on CCQ, CAT (COPD assessment test), dyspnea score and use of rescue medication. Approximately 4,000 patients will be enrolled, and matched with propensity scores. Results: Not applicable for this abstract Conclusions: The LUMIERE study will provide important clinical information on the real-world effectiveness of IND/GLY. Study funded by Novartis Pharma AG. bangalore, India, and 2 Fortis Hosiptal, rheumatology, bangalore, India A 68 yr old presented with three month history of fever, vasculitic rash on his legs,arthralgia,multiple foot ulcers and gangrene of the toes along with recent onset paraesthesia in both hands and feet.Examination revealed left median,right ulnar neuropathy and bilateral common peroneal neuropathy.C-ANCA(by IF) was strongly positive(PR3 titres 120).Sural nerve biopsy showed necrotizing vasculitic neuropathy and diagnosis of GPA was made(BVAS-15).He was treated with intravenous Methylprednisolone(IVMP),IV cyclophosphamide and later switched on to oral steroids.His clinical condition was stable over next two months and skin grafting was done for the ulcers. Two months later,on the above treatment,he presented with acute shortness of breath.Investigations revealed low hemoglobin,leucocytosis and raised inflammatory markers (ESR-120mm/hr,CRP-60 mg/l).Urine routine analysis showed proteinuria 2+ and RBC casts. Chest X-Ray showed extensive confluent opacities bilateral lung fields.Patient was intubated and bronchoscopy done revealed blood in the airways,lavage showed hemosiderin-laden macrophages.A diagnosis of DAH secondary to GPA was made (BVAS-27). IVsteroids and plasmapheresis(six cycles)given while continuing IV cyclophosphamide.However,no improvement in clinical status and continued to be on ventilator(FiO2 > 50%).Inspite of 5gm IVMP and six cycles of plasmapheresis,he didnot improve. RTX 1gm two doses two weeks apart was given.After one week of RTXsignificant improvement with resolution of chest symptoms,improvement in ventilator parameters,followed by resolution of x-ray infiltrates by day10 and successfully extubated. Cyclophosphamide was stopped,azathioprine initiated and tapering of oral steroids continued.Over the last one year,he has remained in complete remission till date(BVAS-3). DAH occurs as a consequence of pulmonary capillaritis in ANCAassociated vasculitides(AAV) with an incidence of 7-45% in GPA.Cyclophosphamide and steroids have been the mainstay of treatment for long. RTX has recently been shown to be effective both for induction and maintenance of remission with a good safety profile. Use of IV steroids and plasmapheresis evidence is restricted to retrospective case series.Data regarding efficacy of RTX in DAH is limited. Background and Aims: Ultrasound(US)-guided percutaneous chest biopsy has been alternative intervention to computed tomographic guided biopsy or transbronchial biopsy for peripheral lung lesions. This intervention seems to be so convenient method that could obtain biopsy samples by bed side without radiation exposure or intravenous agents. We started to apply US-guided percutaneous chest biopsy from the middle of 2014, all which were performed by respiratory physicians. We evaluate efficacy and safety of US-guided percutaneous chest biopsy for diagnosing peripheral thoracic lesions as well as for identifying infective bacterium in case of lung abscess, comparing with the former reviews. Methods: We retrospectively collected 25 patients with peripheral thoracic lesion who underwent US-guided percutaneous chest biopsy during a year from April 2015 to May 2016 in our hospital (420 beds including with 56 respiratory patient beds). 25 lesions (21 lung, 1 chest wall, and 3 mediastinum) were biopsied. 11 of 25 underwent fine needle aspiration at the same time with biopsy. Histopathologic and microbiological analyses were obtained for final diagnosis. Results: 23/25 (92%, 11 malignancy and 12 benign) were diagnosed pathologically, and 2/25 were not identified. 11 microbiological samples were obtained by fine needle aspiration, which were suspected as lung abscess or infection. 9 of 11 benign lesions were diagnosed as abscess pathologically and 4 of them (44.4%) had microbiological isolation by the aspiration samples. Complications occurred in 3 (12%), which were 2 slight pneumothoraxes and 1 pyothorax. Conclusions: Diagnosing yield and complications were still competitive even when US-guided percutaneous chest biopsy was performed by respiratory physicians in a community hospital. Aspiration for microbiological examination should be added in case the lesions are suspected as infectious disease. Complication rates seems to be a little higher than former reviews, but not severe. Pyothorax should be made attention because it sometimes induces severe infection. Background and Aims: The evaluation of pleural effusion includes a combination of clinical history, physical examination, radiology, pleural fluid analysis, percutaneous pleural biopsy and pleuroscopic pleural biopsy. This study is an attempt to compare the eitiological diagnostic efficacy of of Flexirigid pleuroscopic evaluation of patients presenting with pleural effusion, with another set of patients who had pleural fluid analysis and percutaneous pleural biopsy alone. Aims 1. To determine the eitiological diagnostic efficacy of flexirigid pleuroscopic evaluation in patients with pleural effusion. 2. To compare the eitiological diagnostic efficacy of flexirigid pleuroscopic evaluation in patients with pleural effusion, with the diagnostic efficacy of pleural fluid analysis and percutaneous pleural biopsy alone in a different set of patients with pleural effusion. Methods: Study design : Prospective study Study setting The Department Of Respiratory Medicine KIMS Thiruvananthapuram a tertiary health care centre in South India Patients who presented with pleural effusion were selected for the study. Those patients with features suggestive of parapneumonic effusion were excluded. The decision to proceed with videopleuroscopy was taken according to physician's discretion and the patient's consent. The diagnostic efficacy of videopleuroscopy in these patients was compared with the data regarding onother set of patients who had pleural fluid analysis and percutaneous pleural biopsy alone. Results: 21 patients with exudative pleural effusion consented for flexirigid pleuroscopy. Of these we got conclusive results for 17 patients.The diagnostic efficacy was found to be 80.95 percent for flexirigid pleuroscopy. From the analysis of onother set of 69 patients who had pleural fluid analysis and percutaneous pleural biopsy alone, it was found that the diagnostic efficacy of closed pleural biopsy was 61 percent.By pleural fluid analysis alone diagnosis could be confirmed only in 36.6% of cases Conclusions: Flexirigid pleuroscopy has a better etiological diagnostic efficacy for pleuraleffusions compared to pleural fluid analysis and percutaneous pleural biopsy alone Background and Aims Introduction: Pneumothorax is an abnormal collection of air in pleural space. Primary spontaneous pneumothorax (PSP) is defined as the spontaneous occurence of pneumothorax in patients without apparent underlying pulmonary disease, predominantly occurs in young, thin male. PSP results from spontaneous rupture of a subpleural bleb or bulla. However, only a portion of patients with PSP could be found with blebs or bullae in imaging or at the time of surgery. PSP presents with acute onset of local pleuritic chest pain accompanied by shortness of breath. Chest tube drainage can be effective in about 85% -90% of patients on the first episode of PSP. Surgical management of PSP is usually indicated in patients with recurrent ipsilateral pneumothorax, first episode with occupational risk or persistant pneumothorax. Methods: Case report Results: Case A 20 years old non smoking male had suffered a right sided pneumothorax after playing badminton. He has a history of controlled asthma. A chest radiograph showed a complete right pneumothorax. A 32 Fr chest tube drain and -20 cm H 2 O suction couldn't improve the pneumothorax, and it persisted for 29 days. The process of lung expantion was disturbed because of the unstability of the suction machine. IGRA test revealed that he did not suffer from TB infection. Thoracic CT Scan didn't show any structural abnormality. An open thoracotomy was performed and revealed fibrous tissue which attached the superior and inferior right lobe. Decortication of the fibrous tissue could fully expand the right lung. Conclusions: Primary spontaneous pneumothorax predominantly occurs in young thin male. Unstability of lung expantion process results in the growth of fibrous tissue, which can lead the pneumothorax persist. Open thoracotomy and decortication is an invasive technique in management of persistant spontaneous pneumothorax. Background and Aims: Diving is an activity carried out at more than 1 atmosphere absolute (ATA) pressure either in the water or in the Hyperbaric Chamber. Divers will be exposed to several factors that affect lung function and other physiological changes, such as a decrease in ventilation, an increase in physiological dead space and expiratory reserve volume. These changes are reversible due to increased atmospheric pressure and underwater physical work. Our aim is to compare lung function before diving and after giving compressed air during diving at a depth of 5 meters or 1.5 ATA in the hyperbaric chamber. Methods: This is an experimental study involving sixteen skilled divers. Compressed air was applied to 16 skilled divers at 1.5 atmosphere absolute (ATA) which equal to 5 meters dive for 30 minutes. Individual lung function was assessed pre and post treatment in the hyperbaric chamber with suppressed air pressure. Results: There were decreased level of VC, FVC, FEV 1 , FEV 1 /FVC, FEF 25 , FEF 50 , and FEF 75 with an average of 3.75 ml (P >0.05), 76.88 ml (P >0.05), 100.63 ml (P <0.05), 2.46% (P <0.05), 1.03 L/s (P <0.05), 1.36 L/s (P < 0.05), 0.50 L/s (P <0.05) and 0.16 L/s (P <0.05) compared to the basal lung function measurement prior to compressed air application. Conclusions: Compressed air and 1.5 ATA pressure which equals to 5meters dive, can decrease lung functions significantly. Raipur, India, and 2 VPCI, Pulmonary medicine, Delhi, India Background and Aims: FEV1/FVC ratio is an universally accepted parameter to diagnose diseases of airways obstruction. We have described prediction equations for spirometry parameters separately in adults and children for Asian Indians using the 2005 American Thoracic Society/European Respiratory Society (ATS/ERS) recommendations. Given the known negative association of age with FEV1/FVC ratio, we examined if an all-age equation could be developed for FEV1/FVC ratio in Asian Indians 6 years and above from the combined dataset of children and adults. Methods: Normal healthy non-smoker subjects, both males and females, aged 6 years and above underwent spirometry using Fleisch Pneumotach spirometer. The dataset was randomly divided into training (70%) and test (30%) sets. The former was used to develop the equations and validated on the test data set. Prediction equations were developed for FEV1/FVC ratio using multiple linear regression analysis. Results: 1454 (853 males, 501 females) subjects performed spirometry that was technically acceptable. The predictions were about 4% higher in females. Age was the major negative determinant of FEV1/FVC ratio with lesser but positive associations with height and weight. The equations were, Males: 74.866-0.233 × age + 0.107 × ht-0.075 × wt (SEE 5.58) and Females: 73.539-0.330 × age + 0.151 × ht-0.074 × wt (SEE 5.08). The equations were found to be valid on the test dataset with no significant differences between observed and predicted values. The all-age equations had an excellent agreement in adults with those developed earlier by us for the adult dataset. Conclusions: The all-age equations for FEV1/FVC ratio in Asian Indians subjects 6 years and above give similar predictions in adults as the earlier published equations for adults and also allow computation of the predicted ratio in children that was not available earlier. The equations will allow objective diagnosis of airways obstruction in Asian Indians of ages 6 years and above. Niigata University of Health and Welfare, Department of Physical Therapy, Niigata City, Japan, 2 Niigata University of Health and Welfare, Background and Aims: "Breathing assistance" (BA) is a manual technique of chest physiotherapy, which is common especially in Japan. BA is supposed to assist expiration, to increase tidal volume, to improve alveolar ventilation and, therefore, to alleviate dyspnea. The purpose of this study was to examine relationships between the palm surface pressure and the consequent tidal volume during BA. Methods: Ten healthy volunteers (20.6 AE 0.5 years of age) were studied. BA was performed on the lower chest wall at the xiphoid level with the supine position by a trained therapist. During breathing at rest, the therapist gently assisted the breathing only expiratory phase for 3 minutes. The tidal volume was measured using flow sensor and the palm surface pressure was measured using SR software vision numerical (SUMITOMO RIKO Co., Japan). The palm surface pressure during BA was challenged 2 ways, usual and strong pressure. The increases in tidal volume during BA with both ways were compared in this study. Results: During BA, the tidal volume was significantly increased from 0.62 AE 0.09 L to 0.89 AE 0.13 L (p < 0.05; usual pressure), and from 0.54 AE 0.13 L to 0.87 AE 0.15 L (p < 0.05; strong pressure). After BA, the tidal volume returned toward the baseline. The average palm surface pressure was 28.5 AE 1.96 mmHg (usual), and was 35.4 AE 2.41 mmHg (strong). Conclusions: These findings confirmed the beneficial effects of the BA on tidal volume and force of the palm surface pressure. During BA, strong pressure is not required. Relapse group showed significantly more rapid continuous decline of FEV1% compared to non-relapse group (p < 0.05). Conclusions: Although MBPT is not positive in patients with chronic cough, steroid treatment could be carefully considered if the MBPT shows positive trend to BHR and patient has allergic feature. When the continuous decline of FEV1% is more rapid, close attention would be needed for cough relapse. Further study of large scale is required for more clarification. Background and Aims: Despite the advances in antibiotic therapy,thoracic empyema remains a common clinical entity.Mainstay of treatment of pleural empyema is the treatment of ongoing infection and the prevention of recurrent infection and late restriction.Treatment also includes drainage of complicated pleural effusion, full expansion of the underlying lung and elimination of the pleuropulmonary infection with antimicrobial agents.Antimicrobial therapy along with thoracocentasis is usually adequate treatment in early empyema thoracic but chronic cases may requires aggressive intervention. in under developed countries like Pakistan most of the empyema patients present late to the tertiary care hospitals Methods: It is a prospective analysis of 55 patients admitted at Jinnah postgraduate medical centre Karachi, Pakistan from Sept 2014 to Oct 2015, patients were selected and evaluated through nonprobability convenient sampling, who underwent medical thoracoscopy under L/A. P < 0.05 was considered significant with confidence interval taken as 95%. Patients were included on basis of prolonged clinical presentation of more than 30 days, nonresponders to antibiotic therapy (undiagnosed), failure of drainage by chest intubation and radiological findings ( fixed mediastinum, and ultrasound showing loculated effusions, thick pleura and multiple/thick septations. Results: Out of 55 patients 18 were females, 37 were males with mean age 25.37.39(70.9%) patients underwent rigid thoracoscopy with clearing of pus and adhesions followed by pleural biopsy.Tuberculous empyema was found in 35 (63.63%) patients and in 20 (36.36%) patients pleural biopsy on acute on chronic inflammation. Follow-up Chest X-Ray shows complete resolution in 32 (58.18%) partial resolution of more than 50% from the initial X-ray was achieved in 20 (36.36%) patients. 2 patients developed persistent air leak and required surgical intervention.1 patient expired due to septicimia. Conclusions: Rigid thoracoscopy done under local anaesthesia by pulmonologists is a useful technique for dealing with chronic empyema in resource constrained countries where facilities of thoracic surgery is not widely available.Background and Aims: Oseltamivir is an antiviral drug, used for influenza treatment. We reported here a case of influenza B pneumonia treated with oseltamivir and complicated with prolonged weaning from oseltamivir-induced central hypoventilation and hypothermia. Methods: An elderly man presented with fever and dry cough 1 day before admission. On examination, he looked drowsy and had fever with hemodynamic instability. He had oxygen desaturation and fine crepitation in left lung. Chest X-ray showed infiltration in both lower lungs.(figure1) He was initially diagnosed with community acquired pneumonia with sepsis and stabilized with fluid resuscitation, vasopressor and oxygen supplement. Levofloxacin and ceftriaxone were prescribed. Two days later, he developed acute respiratory failure. His chest X-ray revealed progressive infiltration at right lower lung. Rapid test for influenza was positive for influenza-B, resulting in administration of oseltamivir(75 mg twice-daily). Consequently, his symptoms and arterial oxygenation improved. However, during the second week of admission, he could not breathe spontaneously and got a new fever, anemia and thrombocytopenia. (figure1,2) Sputum culture showed heavy growth of Acenitobacter baumannii without new infiltration on chest X-ray. Ventilator associated tracheobronchitis was diagnosed, so antibiotics were switched to Carbapenem, Colistin, and Ampicillin/Sulbactam. Oseltamivir was extended due to concerning of immune response to influenza-B. His condition recovered until the third week of treatment, he developed unexplained hypothermia, occasional hypotension and central hypoventilation despite no sedative drugs and neuromuscular-blockades.(figure2) At that time, his neurological signs including brainstem reflexes were intact. Additionally, there was no evidence of new infection or endocrine crisis. Subsequently, adverse drug reaction was considered, thus we stopped oseltamivir. Dramatically, his temperature, blood pressure, respiratory rate and PaCO2 returned to baseline within a few days after oseltamivir-withdrawal. Finally, he was successfully discontinued from respirator. Conclusions: We demonstrated the case with the uncommon adverse reaction from oseltamivir, namely, hypothermia and respiratory suppression. Background and Aims: The loss of airway epithelial integrity contributes significantly to asthma pathogenesis. Recent reports reveal that Thymic stromal lymphopoietin(TSLP) may have dual immunoregulatory roles. TSLP is present in 2 isoforms, including short and long TSLP. In inflammatory disorders of the bowel,the long-form TSLP(lTSLP) promotes inflammation and the short form of TSLP(sfTSLP) inhibits inflammation. We hypothesize synthetic sfTSLP preventsairway epithelial barrier disruption induced by House Dust Mite(HDM). Methods: Normal human bronchial epithelial cells(16HBE) were stimulated with HDM and 1α,25-Dihydroxyvitamin D3. We evaluated the expression of TSLPs by quantitative real-time PCR and Western blot. Meanwhile, transepithelial electrical resistance (TEER) and fluorescentdextran (FITC-dextran) permeability and distribution of E-cadherin and β-catenin were assessed to evaluate the airway epithelial barrier function. In vivo, BALB/c mice were exposed to HDM by nasal inhalation to set up asthma model in 5 consecutive days per week, sfTSLP and 1α,25-Dihydroxyvitamin D3 were inhaled 1 hour before HDM inhalation. 8 weeks latter, we utilized animal lung function test and pathological staining to evaluate the asthma situation. Results: In vitro, 1α,25-Dihydroxyvitamin D3 upregulated sfTSLP expression and inhibited HDM-dependent upregulation of lTSLP. Using sfTSLP and 1α,25-Dihydroxyvitamin D3 could prevent HDM-induced airway epithelial barrier disruption. Asthmatic mice model was successfully to be established, as inflammatory factors like IL-4、IL-5 and lTSLP in BALF were unregulated in consistent with serum IgE except IFN-γ. Airway epithelial junction proteins was partially lost or dislocated. Moreover, Synthetic sfTSLP and 1α,25-Dihydroxyvitamin D3 ameliorated HDM-induced asthma in mice. Conclusions: The two isoforms, short and long TSLP have a different expression and different biological properties. We emphasize the importance of analyzing the two TSLP isoforms separately. Moreover, our results indicates that sfTSLP and 1α,25-Dihydroxyvitamin D3 may be a novel therapeutic strategy for individualized treatment of asthma.Background and Aims: This is a pediatric case presenting with recurrent pulmonary infiltrates and severe anemia. This patient was eventually diagnosed as having Idiopathic Pulmonary Hemosiderosis (IPH). Early recognition of this disease results in better prognosis. In older literature, IPH was reported to have a high mortality rate, in contrast to recent studies which suggest better prognosis and higher survival rate after early corticosteroid use. Methods: This article describes the case of a 23 month old, female child, who presented with recurrent severe anemia needing multiple blood transfusions. What was striking was that the occurrence of anemia was associated with respiratory symptoms of cough and tachypnea concurrent with pulmonary infiltrates on chest radiography. The diagnosis was clinched after a strong clinical suspicion that the anemia and respiratory symptoms were both part of a single disease entity and were not separate entities or merely coincidental finding. Results: Work up was done to identify the etiology of the pulmonary hemorrhage. High resolution chest CT scan with contrast showed diffuse ground glass opacities with uniform micronodular densities and airbronchogram. An open lung biopsy confirmed the presence of hemosiderin-laden macrophages with no signs of vasculitis or capillaritis, thus, pointing towards IPH. The patient improved and was discharged after initiation of corticosteroid therapy. This is the second case of pulmonary hemosiderosis in our institution in the past 10 years.The other case was secondary to an Autoimmune Hemolytic Disease diagnosed via bronchoscopy with transbronchial biopsy. Conclusions: When given a case of unexplained recurrent anemia coupled with bilateral infiltrates on chest xrays, one should suspect the possibility of pulmonary hemorrhage even in the absence of any respiratory symptoms. The rarity of this disease condition and its variable clinical course resulted in many diagnostic pitfalls leading to late diagnosis and poorer outcome. Untreated, this condition leads to complications that sets in early especially pulmonary fibrosis. Background and Aims: Excessive inflammatory response are critical events in the pathogenesis of acute lung injury (ALI).Activating transcription factor 3 (ATF3) is a stess-induced transcriptional regulator which plays a role of negative regulator in variety of inflammatory responses. Methods: To determine the role of ATF3 in vivo and in vitro,we compared the response of ATF3 gene-deficient mice to wild-type mice in an vivo model of ALI and in an vitro model of RAW264.7 cells.Moreover,we analyzed the differential gene between the lung tissues of ATF3 genedeficient mice and the wild-type mice. Results: We found that the expression of ATF3 was both up-regulated in the lung tissues obtained from the mice model of LPS-induced ALI and the mouse macrophage RAW264.7 cells.The LPS-induced lung tissues inflammatory responses (the pro-inflammatory cytokines include TNFa,IL-6 and IL-1b),lung permeability (BALF protein concentration and lung tissues wet/dry weight ratio),degree of lung injury in pathology,and mortality were intensify in ATF3 gene-deficient mice.Consistent with the abovementioned that the inflammatory reactions (the pro-inflammatory cytokines include TNF-a and IL-6) were both intensify in ATF3siRNA-treated RAW264.7 cells.TL1A was highly expressed in LPS-induced lung tissues of ATF3 gene-deficient mice by differential gene analysis.Moreover,we found that ATF3 could down-regulate the expression of TL1A in RAW264.7 cells.Both down-regulated the expression of ATF3 and TL1A in RAW264.7 cells,the level of IL-6 was significantly attenuated. Conclusions: ATF3 protects against LPS-induced ALI via inhibiting the expression of TL1A. Background and Aims: Ewing sarcoma accounts for 3% of all pediatric malignancies, with rib involvement accounting for 12%. Extension into the thoracic cavity can cause cardiopulmonary compromise. Pneumonectomy is rarely performed in children except in malignancy. Methods: This is an eight-year old male with recurrent, dull pain over the right chest associated with cough and dyspnea. Pertinent findings were tachypnea, absence of lymphadenopathy and absent breath sounds over the right hemithorax. Chest xray showed an opacified right hemithorax. Chest CT scan showed a well-defined mass, which, on 2D echocardiogram, was seen to be compressing on the right atrium, causing cardiopulmonary compromise. The mass was resected, along with the right lung, which was entirely compressed, and segments of the right 4th-6th ribs. Final tissue biopsy revealed an osseous primitive neuroectodermal tumor / Ewing sarcoma (T2N0M1). A postoperative pulmonary function test showed a restrictive ventilatory defect. The patient was discharged improved and underwent chemotherapy and radiation therapy post-operatively. Ewing sarcoma originating from the ribs may have a soft tissue mass that is disproportionately large compared to the intraosseous involvement. Malignancy is the most common indication for a pneumonectomy. Changes are elevation of the ipsilateral hemidiaphragm, hyperinflation of the remaining lung, shifting of the mediastinum towards the postpneumonectomy space (PPS), and progressive resorption of air in the PPS and replacement with fluid. Fluid accumulates in the postpneumonectomy space and its careful management is vital to maintain hemodynamic and respiratory stability. Post-operatively, one-lung ventilation entails low tidal volume, high PEEP and a low FiO2. A restrictive ventilatory defect is common among postpneumonectomy patients. Conclusions: This is an 8-year-old male who underwent a right pneumonectomy for a Ewing sarcoma of the rib with intrathoracic extension. Children with chest pain and suspicious bone growths should be thoroughly investigated. Background and Aims: Large cell neuroendocrine carcinoma (LCNEC) is a highly aggressive tumor with a poor prognosis. The current treatment is rarely curative for advanced LCNEC; as such, novel effective therapies are urgently needed. Inhibition of Hedgehog (Hh) signaling, especially Gli activation, has shown anti-cancer activity in several cancers in recent clinical studies. However, the role of the Hh pathway in LCNEC has not yet been elucidated. The current study attempted to evaluate in vitro the potential of Gli as a therapeutic target for treating LCNEC. Conclusions: These findings suggest that Gli activation plays a critical role in LCNEC and that drugs with strong suppression of Gli are needed. Inhibition of Gli function has the potential to become an effective approach to treating LCNEC. Yodogawa Christian Hospital, Department of Pediatric Surgery, Osaka, Japan, and 2 Yodogawa Christian Hospital, Department of Surgery, Osaka, Japan Background and Aims: Introduction: The Nuss procedure is currently the standard operation for the repair of pectus excavatum owing to the minimal invasiveness. Metal bars are inserted behind the sternum and through the mediastinum and removed after about 2 years. This procedure has many advantages such as a short operating time, minimal blood loss and the need for only small incisions. Temporary communication between the chest cavities is produced as a result of the Nuss procedure. We present a case of iatrogenic buffalo chest, resulting in a bilateral pneumothorax in the early postoperative period following the Nuss procedure. Methods: Case report: A 17-year-old man with pectus excavatum underwent the Nuss procedure. The patient's condition was good for a few days, but he suddenly suffered from dyspnea, leading to respiratory failure at 4 days postoperatively. An X-ray revealed the presence of a bilateral pneumothorax, therefore, endotracheal intubation and bilateral chest drainage were immediately performed. Preoperative computed tomography (CT) revealed the presence of a bulla in the apex of the right lung. We considered the spontaneous pneumothorax a result of a ruptured bulla in the right thorax, which spread to the left side through the inserted bar. His respiratory condition improved following intubation and chest drainage, although air leakage continued from both sides of the thorax. A video-assisted right bullectomy was performed on postoperative day 10. He was discharged from hospital 17 days after the Nuss procedure. Results: Discussion: Several opinions exist on the clinical relevance of a bulla identified before the Nuss procedure. In this case, a ruptured bulla, which occurred in a patient with iatrogenic buffalo chest caused by the Nuss procedure, led to a bilateral pneumothorax that left the patient in a critical condition at 4 days postoperatively. Conclusions: We recommend bullectomy before the Nuss procedure, if preoperative CT reveals the presence of a bulla. Background and Aims: Asthma is a chronic inflammatory disorder of the airways associated with bronchial hyperresponsiveness and permanent structural changes. These changes named bronchial wall remodeling including loss of epithelial integrity, submucosal gland enlargement, hypethrophy of airway muscle cells and subepithelial fibrosis. Additionally, increased secretion of inflammatory cytokines and growth factors especially TGFβ 1 stimulates fibroblast to myofibroblast transitins (FMT) in the respiratory tract. We observed that unstimulated asthmatic bronchial fibroblasts form thick and aligned 'ventral' stress fibers accompanied by enlarged focal adhesions. It correlates with higher elastic modulus of them and their increased predilection to TGF-β 1 -induced FMT. Formins play a crucial role in the polymerization of actin and they are involved in the organization of actin filaments. Most formins are Rho-GTPase effector proteins. Because formins regulate stress fibers formation and rearrangements of actin cytoskeleton architecture, their RhoAdependend activity may be important for the increased FMT in bronchial fibroblasts derived from asthmatics. Methods: Human bronchial fibroblasts from asthmatic donors (HBF AS) were cultured in DMEM with 10% FBS. For experiments, cells (5 th -15 th passage) were plated in serum-free medium, pre-treated with inhibitors (Y-27632, SMIFH2) and stimulated with TGF-β 1 . Genes expression was estimated with qRT-PCR analyses, relative number of myofibroblasts was determined by immunofluorescence, whereas Western blot was used for the analysis of FMT-and formin-related protein levels. Results: TGF-β 1 stimulates the expression of key genes in Rhodependent pathway. Chemical inhibition of ROCK1 significantly attenuated mDia2, ROCK1/2 and genes expression from Smad pathway. This translates into significant reduction of TGF-β 1 -induced FMT efficiency in HBF AS populations. Conclusions: Non-canonical for TGF-β 1 -induced FMT, Rho-dependent pathway which activates formins, regulates α-SMA expression in 'asthmatic' bronchial fibroblasts and determines the efficiency of their myofibroblastic differentiation. Funded by KNOW whose beneficiary is Faculty of BB&B of Jagiellonian University (projects for young scientists, dec. nr KNOW 14/2016). Background and Aims: Asthma is a worldwide chronic disease affecting people of all ages. It was documented that the chronic inflammatory reaction within lung tissue causes the remodeling of bronchi wall leading to the bronchoconstriction. The one of the main actors in the remodeling are miofibroblasts, the cells differentiating from the bronchial fibroblasts in the process known as fibroblast-to-miofibroblast transition (FMT).Transforming growth factor β plays as main FMT trigger acting by its canonical pathway dependent on SMAD proteins. As a result of TGF β pathway activation SMAD2 proteins are phosphorylated and translocated to the cell nuclei where they act as transcription factor starting FMT. It has been emphasized that endocytosis may play a pivotal role in the TGF β pathway activity by regulation of signal transduction and the TGF β receptor degradation or recycling. The aim of study was to investigate in details the potential roles of endocytotic routes in the regulation of FMT intensity after TGF β stimulation. Methods: Human bronchial fibroblasts from asthmatic (HBF AS) and non-asthmatic (HBF NA) donors were cultured in DMEM with 10% FBS. Next incubated in serum free medium supplemented with inhibitors of the different endocytic routes and analysed with fluorescence microscopy and flow cytometry Results: Dynazor affected the TGFβ signaling of both asthmatic and nonasthmatic lung fibroblasts leading to decrease of SMAD2 phosphorylation and nuclei transolocation and thereby blocking FMT. The similar results were observed after blocking the macropinocytosis by amylorid. In the same time we observe weaker effect of nystatinan inhibitor of lipid-raft / caveolae-mediated endocytosis on the intensity of human lung fibroblast FMT. Methods: BPD of neonatal mice models were established by exposing in constant hyperxia condition C57BL /6 56 mice (2 d of birth ) were randomly divided into BPD group ( n = 28) and air group (n = 28). The mice in BPD group were exposed in 70% AE 5% oxygen concentration of incubators and 7 mice in the two groups were respectively killed on 3 st d,7 th d, 14 th d and 21 st d after birth and then changes of pulmonary tissue structures and radial alveolar counting (RAC) in removed lung tissues were observed. DcR3 expressions were detected by immunohistochemical method.microvessel densities (MVD) and average optical density (AOD) were counted by image pro plus 6.0 software. Results: Compared with those of air group DcR3 expressions were obviously increased, and MVD were obviously decreased alveolus numbers were simplified in BPD group. RACs were significantly decreased on 7 th d, 14 th d and 21 th d after birth in BPD group compared with those of air group and levels of MVD and AOD on 14 th dand 21 st d after birth were significantly higher than those in air group P < 0. 056. Conclusions: Constant high concentration of oxygen inhalation can induce pulmonic microvascular dysplasia decreased MVD and higher levels of DcR3 expression of vascular endothelial cells in neonatal mice and it may play an important role in the BPD pathogenesis.