key: cord-0042019-7wqdlha4
authors: nan
title: Oral Session
date: 2010-11-24
journal: Respirology
DOI: 10.1111/j.1440-1843.2010.01864.x
sha: a8c3dcbb3da76aa236fa43c2d46e521e6912e2ec
doc_id: 42019
cord_uid: 7wqdlha4

nan

Introduction Rheumatic heart disease, predominantly mitral stenosis is a chronic disease that produces an increase in the left atrial pressure and consequently venous pulmonary hypertension. Preoperative lung function which could be obtained from spirometry can evaluate respiratory reserve in cardiopulmonary patients who will undergo surgery. However, data on the use of spirometry in predicting the rate and extent of regression of preoperative pulmonary artery hypertension is limited. Methods We determined the usefulness of preoperative lung function by spirometry in predicting regression of pulmonary hypertension after surgical correction of mitral stenosis among 20 patients who underwent mitral valve surgery at Philippine Heart Center from July to December 2009. Results Among the twenty patients included in the study, one had normal spirometry and another one had mild obstructive abnormality. Majority of the patients (18/20) had restrictive abnormality. Nineteen patients had regression of PAP. Among them, 18 patients were noted to have restrictive abnormality and one with normal spirometry. There was only one patient who did not have regression of PAP and found to have a mild obstructive abnormality. Correlation of the severity of restrictive lung defect with the change in PAP classifi cation among nineteen patients showed lack of correlation with a spearman coeffi cient of 0.041 and p-value of 0.863. (Figure 1 ) Conclusion This study showed that majority of RHD patients particularly mitral stenosis will have a preoperative spirometric abnormality of restrictive pattern. Among the study group, almost all patients (19/20) will have regression of pulmonary hypertension after surgery except for one patient with obstructive lung abnormality. Though results were not signifi cant, we cannot conclude that preoperative lung function is not predictive of regression of pulmonary hypertension after surgical correction of mitral stenosis due to inadequacy of sample size. Thus, further investigation is warranted. Introduction Drug-induced interstitial lung disease (ILD), particularly pulmonary fi brosis, is a serious clinical concern and myofi broblasts have been suggested to play a major role, with it recently being revealed that some of these myofi broblasts are derived from lung epithelial cells through epithelial-mesenchymal transition (EMT). In this study, we used cultured epithelial cells to examine the EMT-inducing abilities of drugs known to induce ILD clinically. Methods Induction of EMT in cultured lung epithelial cells were monitored by up-regulation of the expression of myofi broblast marker proteins and downregulation of the expression of epithelial cell marker proteins. The severity of lung injury and fi brosis in mice was assessed by various methods, such as histopathologic evaluation, histochemical analysis of collagen and determination of hydroxyproline. Results EMT-like phenotypes were induced by A771726, an active metabolite of lefl unomide having an inhibitory effect on dihydroorotate dehydrogenase (DHODH). Smad interacting protein 1 (a transcription factor regulating EMT) and the Notch-signaling pathway were shown to be involved. When the cultures were supplemented with exogenous uridine, the A771726-induced EMTlike phenotypes disappeared. Likewise, an A771726 analog without inhibitory activity on DHODH produced no induction, suggesting that this process is mediated through the inhibition of DHODH. In vivo, administration of lefl unomide stimulated bleomycin-induced EMT-like phenomenon in pulmonary tissue, and exacerbated bleomycin-induced pulmonary fi brosis, both of which were suppressed by co-administration of uridine. Conclusion These fi ndings suggest that lefl unomide-dependent exacerbation of bleomycin-induced pulmonary fi brosis is mediated by stimulation of EMT of lung epithelial cells, providing the fi rst evidence that drug-induced pulmonary fi brosis involves EMT of these cells. We consider that this lefl unomide-dependent exacerbation of bleomycin-induced pulmonary fi brosis provides a suitable animal model of drug-induced ILD, which is important to establish not only a clinical protocol for its treatment but also an assay system that will facilitate screening in order to eliminate candidate drugs with the potential to produce this type of side effect.

Introduction To observe the infl uence of arsenic trioxide on the bleomycininduced pulmonary fi brosis in rats and its mechanisms. Methods Pulmonary fi brosis was induced in Sprague-Dawley (SD) rats by intratracheal instillation of bleomycin(BLM). The rats of the treatment group, the steroid group and model group were intraperitoneally injected with arsenic trioxide(ATO), dexamethasone or normal saline(NS)respectively, while the control rats received NS both intratracheally and intraperitoneally. The effects of interference were evaluated by median survival time, hydroxyproline level in lung, semi-quantitative grading of alveolitis and pulmonary fi brosis and quantititative analysis of collagen in lung (Masson's trichrome stain). Apoptosis index (AI) of lung was detected by using the terminal transferase dUTPdigoxygenin nick end-labeling (TUNEL) method and the results of the immunohistochemical staining of some cytokines were quantitatively analyzed. Results ATO might (1) prolong the median survival time of BLM-induced pulmonary fi brosis rats at some extent; (2) attenuate the alveolitis and pulmonary fi brosis, reduce hydroxyproline level and collagen deposition in lung tissue; (3) increase the AI of lung tissue at a certain phase; and decrease the levels of transforming growth factor-β1 (TGF-β1) and tissue inhibitor of metalloproteinase-1 (TIMP-1), increase the content of interferon-γ(IFN-γ) signifi cantly. Conclusion ATO might attenuate BLM-induced pulmonary fi brosis in rats via increasing the AI of lung tissue.

Introduction Combined pulmonary fi brosis and emphysema (CPFE) is a syndrome involving both emphysema and diffuse parenchymal lung disease with fi brosis on chest computed tomography (CT). The clinical characteristics of CPFE have been described; however, the differences between the syndrome and interstitial pneumonia (IP) or chronic obstructive pulmonary disease (COPD) are not fully understood. The purpose of this study was to clarify the differences in respiratory resistance and reactance using a forced oscillation technique. Methods The subjects included 26 patients with CPFE, 27 with IP, and 21 with COPD. Respiratory resistance and reactance were measured using Most-Graph-01 (CHEST MI Co., Ltd., Tokyo, Japan), and pulmonary function tests were also performed on the same examination day. Results The FEV1 and FEV1/FVC values were signifi cantly lower in COPD patients compared to those with CPFE and IP. There was no signifi cant difference in VC between CPFE, IP, and COPD patients. The carbon monoxide transfer coeffi cient values were signifi cantly lower in CPFE and COPD patients compared to those with IP. Resistance at 5 Hz (R5: cmH20/L/s) was significantly elevated in patients with COPD (CPFE, 3.48; IP, 4.20; and COPD, 4.56, respectively, p < 0.05 for CPFE vs. COPD), while R20 was elevated in patients with IP and COPD compared to those with CPFE (CPFE, 2.53; IP, 3.47; and COPD, 3.24, respectively, p < 0.05 for CPFE vs. IP and for CPFE vs. COPD). The resonant frequency (Hz), a parameter of reactance, was signifi cantly higher in COPD patients compared to CPFE and IP patients (CPFE, 8.76; IP, 9.09; and COPD, 15.50, respectively, p < 0.05 for CPFE vs. COPD and for IP vs. COPD). Conclusion CPFE patients exhibited no airfl ow limitation or restrictive impairment, but showed severe gas exchange abnormality similar to that in COPD patients. The absence of an elevation of respiratory resistance or reactance refl ects homogenous ventilatory mechanics in CPFE, thereby differentiating it from IP and COPD. These results suggest that CPFE is a distinct syndrome differing from IP or COPD. Pneumonectomy is a surgical removal of a lung. It poses several adverse consequences as it substantially diminishes diffusion capacity by reducing total number of alveoli and vasculature available for gas exchange. The challenge is to maintain adequate gas exchange following resection of the lung tissue. Literature revealed a good prognosis for pneumonectomized infant. There is enhancement of diffusion capacity in remnant lung through generation of new pulmonary gas exchange units. This was evidenced by normal lung volumes of the pneumonectomized infants after 20 years. In this article, we present a 22 day old female who was noted to be tachypneic, with chest indrawing and subcostal retractions. Chest roentgenogram done revealed collapsed right lung, dextrocardia with hyperinfl ated and hyperluscent left lung. 2D echo showed no anatomic anomaly, except for dextroposed heart probably secondary to the collapsed right lung. Impression then was Congenital Cystic Adenomatoid Malformation versus Congenital Lobar Emphysema, left lung. Extensive work-up was done. Chest CT scan showed overly infl ated and hyperluscent lung segment arising from left lower lobe which is characteristic of a congenital lobar adenomatoid malformation. Lung perfusion scan demonstrated diminished perfusion of the left lung with differential contribution to the total perfusion of the 38% left lung and 62% right lung. Patient then underwent open thoracotomy with pneumonectomy of the left lung. Biopsy revealed Congenital Cystic Adenomatoid Malformation Type II. Three months after the surgery, she has gained weight, not receiving any medications and is symptom free.

Introduction Despite the importance of infection and infl ammation in the pathogenesis and management of bronchiectasis, there are few published data on lower airway microbiology and cellularity in these children. Methods Children attending a single centre (1992 to 2009) with non-cystic fi brosis bronchiectasis who underwent bronchoalveolar lavage (BAL) within 4 weeks of diagnosis were identifi ed. The point prevalence of infection (>105 colony-forming units (CFU)/mL of respiratory bacterial pathogens), its effects upon airway cellularity and the impact of clinical and demographic variables on infection risk were evaluated. Results Of 113 children with bronchiectasis, 44 (39%) had BAL evidence (>105 CFU/mL) of infection, which was frequently polymicrobial and caused mostly by Haemophilus infl uenzae, Streptococcus pneumoniae and Moraxella catarrhalis. In contrast, Pseudomonas aeruginosa was uncommon and mycobacterial and fungal species were undetected. Upper airway commensal organisms were also isolated in large numbers (>105 CFU/mL) from 24 (21%) BAL cultures. The median (interquartile range; IQR) BAL fl uid total cell counts (TCC × 106/L) and neutrophil percentages were signifi cantly higher in those with, than without, infection [TCC 730 (320-4140) vs 280 (143-1131); P = 0.001 and neutrophil percentage 76% (22-94) vs 38% (12-80); P = 0.01 respectively]. Only age at diagnosis was associated with infection. Conclusion BAL microbiology of children with newly diagnosed bronchiectasis substantially differs from adults. Children have marked airway neutrophilia, particularly when bacterial loads were high. Younger children were more likely to have a lower airway infection at diagnosis. The role and interactions of respiratory bacterial fl ora in initiating and progressing airway damage in bronchiectasis requires further study.

The radiological defi nition of airway dilatation and bronchiectasis in children has substantial limitations. Bronchoarterial ratio is a commonly used criterion to defi ne airway dilatation despite the lack of normative pediatric data. The objective of our study was to determine the range of normal bronchial to accompanying arterial diameter ratio on high resolution CT scan of the chest in children and compare it with the available adult data. Methods Children undergoing MDCT chest for non-pulmonary conditions at a single centre were prospectively identifi ed. High resolution reconstruction was performed on those included and both airway and vessel diameters were measured in the upper and lower lobes of both lungs. Mean bronchoarterial (BA) ratio was calculated for each included child and its correlation with age assessed. Results Forty one children were included, the mean (SD) BA ratio was 0.626 (0.068) (range 0.437 to 0.739). This ratio was clinically similar though statistically lower than comparable adult data [combined mean (SD) 0.676 (0.12); p = 0.01]. No correlation was found with age in our cohort (r = −0.21, p = 0.19). There was no difference in the ratio based on laterality or lobe. Conclusion In pediatric age-group, the airway is signifi cantly smaller than the adjoining vessel. Using the radiological criteria of BA ratio greater than one to defi ne bronchial dilatation would under estimate the presence and extent of bronchiectasis leading to delayed and missed diagnosis. This highlights the need to redefi ne the criteria for bronchial dilatation in children.

Introduction Sleep disordered breathing, especially obstructive sleep apnea syndrome, has been found to be associated with endothelial dysfunction in both adult and paediatric populations. However, the role of non-apnoeic snoring on endothelial function has not been investigated. Methods Children aged 6-18 years with habitual snoring were recruited from our sleep disorder clinic. Non-snoring controls were recruited from participants of a community growth survey. All participants underwent nocturnal polysomnography (PSG) and ultrasonographic fl ow mediated dilation (FMD) evaluation on the same day. Fasting blood was taken for glucose level and lipid profi le determination. Subjects with an obstructive apnoea hypopnoea index (OAHI) < 1 but reported by parents to have habitual snoring (at least 3 nights per week) in the past 12 months were defi ned as primary snorers (PS). Those having an OAHI < 1 without habitual snoring in the past 12 months were grouped as non-snorers. Children with body mass index of greater than the 85th percentile of the local reference were defi ned as overweight. Subjects were divided into groups of normal weight, overweight, non-snorers and PS for comparisons. Results In total, 161 children, of whom 78 were boys, with a mean (SD) age of 11.8 (2.8) years were recruited. Sixty-six of them were PS. Subjects with PS had signifi cantly reduced FMD than non-snoring controls for both the normal weight group (p = 0.040) and the overweight group (p = 0.039) ( Table 1) . Multivariate linear regression model showed that primary snoring (p < 0.001) were independently associated with FMD after controlling for possible confounders including overweight, gender, baseline vessel diameter and log-transformed OAHI. Conclusion Primary snoring in children is independently associated with impaired endothelial function.

Introduction Children with cyanotic congenital heart disease live with baseline oxygen saturations in the mid 70s, so hence they exist on the steep part of the oxyhemoglobin dissociation curve. These patients are at increased risk for the hemodynamic variations occurring during apneas/hypopneas. Longterm outcomes for children with congenital heart disease could be adversely affected since the etiology of pulmonary hypertension is believed to be secondary to the hypoxia and hypercarbia seen in chronic airway obstruction paired with the sympathetic overstimulation caused by frequent sleep arousals. Methods A prospective two part questionnaire for the screening of SDB for pediatric patients was performed. Part one consists validated Pediatric Sleep Questionnaire (PSQ). Part two consisted of subjective assessment of the subject's cardiovascular and respiratory symptom. All odd ratios of greater than 1 with p-values less than 0.05 were considered signifi cant covariates. Results A total of 206 children met the inclusion criteria and were included in the fi nal analysis. The prevalence of sleep disordered breathing (SDB) was high at 63.1%. Among the factors analyzed, an increased frequency of pulmonary diseases (greater than 7 times/year) was statistically correlated with increased PSQ scores (p = 0.002). Likewise, early palliative repair (p = 0.001) was statistically associated. A high total cardiac score is almost four times associated with increased PSQ ratings (p = 0.018). Conclusion Increased frequency of pulmonary diseases and early palliative repair was statistically correlated with increased Pediatric Sleep Questioner scores. A high total cardiac score is almost four times associated with increased PSQ ratings. Hence patients with congenital heart disease and Sleep Disordered Breathing are more likely to have worse cardiac symptoms. Patient with congenital heart disease shoukl be routinely examined for the presence of Sleep Disordered Breathing because these sub group of pediatric patients are 7x have more high risk for developing Sleep Disordered Breathing.

Introduction Atelectasis, is a common pulmonary complication of patient who underwent open heart surgery. Deep breathing exercise is one of the interventions implemented to prevent the occurrence of this complication postoperatively. Among preschoolers however, making them perform this breathing exercise and maintaining compliance is a challenge since children in this age group have a short attention span and may get bored easily. With this problem at hand, the investigators conceptualized an innovative technique, blowing bubbles as a breathing exercise, in order to prevent Atelectasis among post open heart surgery preschoolers. Methods This study is an open-label randomized control trial that compared blowing bubbles with the traditional deep breathing exercise among preschoolers who underwent open heart surgery. It took 4 months to complete the study and there were 64 patients screened but only 60 qualifi ed based on the inclusion/exclusion criteria. Thirty were assigned randomly to the blowing bubbles group and 30 to the deep breathing exercise. Atelectasis as documented on chest X-rays was the outcome measured. Results Out of the 30 participants in the deep breathing group, 8 developed atelectasis while in the blowing bubbles group, 1 out 30 had atelectasis This generated a p-value of 0.026 which is statistically signifi cant, favoring the blowing bubbles group. Furthermore, risk analysis showed an absolute risk reduction of 23.34% and a relative risk of less than 1 which means that atelectasis is less likely to occur in the blowing bubbles group in comparison to the traditional breathing exercise group. Conclusion Blowing bubbles signifi cantly reduces the occurrence of atelectasis among post-open heart surgery preschoolers as opposed to deep breathing exercise. The use of blowing bubbles as a deep breathing modality incorporated through play activity is recommended among preschoolers.

Introduction Severe acute respiratory syndrome (SARS) is a novel contagious respiratory infection caused by the SARS coronavirus (SARS CoV). In adults, a mortality rate of 10% has been reported, and respiratory complications can occur in up to 20% of survivors. The disease pattern is different in children [1, 2] but prevalence of longer term respiratory complications in children is unknown. The aim of this study was to investigate the aerobic capacity of children at 3 years after the diagnosis of SARS. Methods Twenty-seven patients (mean age of 17.7 years) who completed both pulmonary function and maximal aerobic capacity (peak VO 2 ) tests at 6 and 15 months after the acute illness were invited for re-assessment. They underwent anthropometric assessment, full pulmonary function and exercise treadmill test. Subjects with abnormal HRCT at 15 months underwent repeat scanning. Results At this 36-month assessment, 6 subjects refused to take part, and the main reasons of refusal were work commitments or time clashes with school activities. The remaining 21 subjects (43% female) provided complete pulmonary function and exercise data. Pulmonary function test was normal in all patients. Peak VO 2 , peak oxygen pulse, and ventilatory anaerobic threshold (VAT) at this assessment were signifi cantly higher than that recorded at 6 and 15 months. Ventilatory effi ciency (ventilatory equivalents for oxygen, VE/VO 2 ) and perfusion to the lungs (end-tidal partial carbon dioxide pressure, PETCO 2 ) signifi cantly improved since 15 months and maintained at 36 months. Though peak VO 2 further improved at 36 months in patients with persistent or without radiological abnormalities, their values were 65% and 81% respectively of normal controls. Conclusion This study is the most comprehensive report of post-SARS exercise responses in children and adolescents. Improvements in aerobic capacity over a period of 36 months after the initial illness were demonstrated, but the values remained suboptimal when compared to normal reference.

Introduction Domestic mites are an important source of indoor allergens responsible for the development of allergic diseases worldwide. To date, there is no local epidemiology data on the allergic sensitization to domestic mites among adult patients with asthma and allergic rhinitis. Methods From November 2009 to June 2010, we prospectively recruited adult patients with asthma and/or allergic rhinitis from an urban-based specialist medical centre in Penang, Malaysia, carefully profi ling their allergic sensitization to domestic mites by means of skin prick tests and clinico-demographic details.

Of the 60 patients [mean age (CI) 29 years (26-32); 35% male] recruited, skin allergic rates to Dermatophagoides pteronyssinus, D. farinae, Blomia tropicalis and Tyrophagus putrescentiae were 71%, 75%, 70% and 56% respectively. There was no signifi cant difference in these rates among patients with asthma, allergic rhinitis or both. There were signifi cant associations between the number of people living in the same house with rates of D. pteronyssinus (p = 0.05) and D. farinae (p = 0.02), and the frequency of bed sheet changing with the rate of Tyrophagus putrescentiae (p = 0.02). With younger age, there were also signifi cant higher allergic rates with D. pteronyssinus (p < 0.006), D. farinae (p < 0.001), B. tropicalis (p < 0.002) and Tyrophagus putrescentiae (p = 0.04). Conclusion Our preliminary data shows a high prevalence of allergic sensitization to domestic mites in our local adult patients with asthma and/or allergic rhinitis. The fi ndings have implication on allergen control with the view of disease mitigation.

Introduction A study was carried out to compare the effi cacy and sensory perception of Mometasone furoate and Ciclesonide aqueous nasal spray in moderate-severe allergic rhinitis. Methods A single blind study of 3 months on patient of both sexes, >18 years, diagnosed as moderate-severe allergic rhinitis as per ARIA workshop(2008)1, with skin test positivity to at least two aeroallergens was carried out on 52 patients. Patients were divided into two, i.e. mometasone (group A) and ciclesonide groups (group B). Group A received 200 microgram/day of mometasone furoate and group B received 200 microgram/day of ciclesonide, nasal spray once daily in the morning. The evaluation was made at 0, 2, 4, 8, 12 weeks by Total Nasal Symptoms Score (TNSS), Visual Analogue Scale (VAS) and Sinonasal Outcome Test-22 (SNOT-22). Sensory perception of both nasal steroids was carried out on initial visit before allocating groups, employing a sensory perception questionnaire with a 14 sensory items (100 points scale). Patients were given one nasal spray, and immediate and after two minutes response was noted in questionnaire. After 30 minutes of washout period, second drug was given and response was noted in similar way. Results After 3 months, both mometasone and ciclesonide signifi cantly decreased nasal symptoms as assessed by TNSS (p-value = 0.003) and VAS (p-value = 0.004) and improved quality of life signifi cantly as assessed by SNOT-22 (p-value = 0.003). However there was no statistically signifi cant difference among two drugs. The sensory perception, in favour of mometasone was observed immediately after drug administration, than ciclesonide by providing more comfort during administration, less irritation, odor prference (all p-value 0.002 to 0.004). However, after 2 minutes of drug application, there was no signifi cant difference among both drugs in strength of taste, amount of medication rundown and irritation. The overall acceptance by patients was for mometasone over ciclesonide (p-value = 0.003). Conclusion Both mometasone and ciclesonide adequately controlled symptoms of allergic rhinitis in 3 months. The sensory perception preference for many of the sensory attributes in mometasone group were in favour of mometasone. Thus, mometasone has equal effi cacy but slightly better acceptability over ciclesonide in the treatment of allergic rhinitis. Results Of 1460 patients, 62.3% were male and 37.7% females. 79% patients had used alternative asthma therapies: Homeopathy, Ayrurveda and Yoga with poor results and 23.8% had used multiple therapies prior to visit our centre. Patients reported being afraid of acute attack (42.8%) and hospitalization (28.8%). Although inhalers were used by Indian patients in 54.7% but still oral drugs were used regularly by 41.6% patients. Compared to 27.1% in 2002 only 6.1% were inhaler naïve (t-value 0.00018). Only 540/850 (63.5%) patients were using spacer with MDI's and 48% (260/540) being able to demonstrate correct use. Common errors seen in MDI's use were: A) slow and steady inhalation (48.1%) and B) breath holding after deep inhalation (42.5%). Formoterol and budesonide DPI was considered most effective by Indian patients in controlling disease when asked to rate their devices and drugs. When counseled by experts 86% were sure to be regular on treatment but 6 month latter 61% remained regular (t-value 0.00007). Fear of addiction (32.7%) and cost of therapy (25.4%) were cited causes for noncompliance. Conclusion Indian patients use alternative therapy for asthma treatment before coming to tertiary centre and still prefer oral therapy. Despite extensive education being afraid of attacks become noncompliant due to fear of addiction and cost of therapy.

The oesophagus and airways have a common origin. Refl uxrelated respiratory symptoms may be triggered by aspiration of gastric refl uxate into airways or a vagally mediated oesophago-tracheo-bronchial. This association has not been reported previously in Sri Lanka. The aim of this study was to describe the association between gastro-oesophageal refl ux (GOR) events and respiratory symptoms in a cohort of adult asthmatics in Sri Lanka. Methods Thirty stable, mild asthmatics (American Thoracic Society criteria) underwent dual-sensor ambulatory oesophageal pH monitoring. Respiratory symptoms (cough, wheeze, diffi cult breathing, chest tightness) during monitoring were recorded and correlated with refl ux events. Results Both proximal and distal GOR parameters were signifi cantly higher in asthmatics than controls (P < 0.050; Mann-Whitney U-test). However, there was no difference in any parameter between asthmatics with and without respiratory symptoms. Abnormal proximal acid refl ux was documented in 66.7% and distal refl ux in 73.3% of 30 asthmatics. Of 102 respiratory symptoms in all asthmatics, majority (72%) were cough episodes. In total, 93% of coughs, 81% of wheeze and all of chest tightness was refl ux-associated, where in most, refl ux events preceded respiratory symptoms. Of 15 asthmatics with respiratory symptoms, acid exposure was normal in 4 (26%), abnormally high in proximal oesophagus in 9 (60%) and abnormally high in the distal oesophagus in 11 (73%) and abnormal at both levels in 8 (53%). Most refl ux events in asthmatics occurred in the upright position. Conclusion Asthmatics have more GOR and associated respiratory symptoms than non-asthmatic volunteers, with refl ux episodes preceding respiratory symptoms in most cases. Distal GOR and upright acid exposure was more prominent than proximal GOR.

In 1999, fi rst population-based studies to determine the magnitude of the asthma problem have been carried out in Bangladesh, to defi ne the prevalence of asthma and to identify the risk factors of asthma in Bangladesh. After 10 years, same study carried out to fi nd out trends of asthma in Bangladesh.

Methods A cross-sectional study was conducted from January 1999 to August 1999 on 5642 people and same study carried out from November 2009 to April 2010 on 5256 subjects. Data collected from stratifi ed randomly selected primary sampling units of all 64 districts. Face-to-face interviews were performed with housewives or other guardians at the household level using a structured questionnaire. Results In 1999, the prevalence of asthma (wheeze in the last 12 months) was 6.9% (95% CI: 6.2-7.6) whereas in 2010 it is 7.67% (95% CI: 7.59-7.75).

In 1999, prevalence of other asthma defi nitions were: ever wheeze (lifetime wheeze) 8.0% (95% CI: 7.3-8.7); perceived asthma (perception of having asthma) 7.6% (95% CI: 6.9-8.3); doctor diagnosed asthma (diagnosis of asthma by any category of doctor either qualifi ed or unqualifi ed) 4.4% (95% CI: 3.9-4.9). In 2010, ever wheeze (lifetime wheeze) 8.6% (95% CI: 8.52-8.69); perceived asthma (perception of having asthma) 8.31% (95% CI: 8.23-8.40); doctor diagnosed asthma (diagnosis of asthma by any category of doctor either qualifi ed or unqualifi ed) 6.26% (95% CI : 6.20-6.33).The prevalence of asthma in children (5-14 years) was higher than in adults (15-44 years) (7.3% versus 5.3%; odds ratio [OR] = 1.41, 95% CI: 1.09-1.82). Trends of Asthma in Bangladesh remains, almost static over last 10 years although at present prevalence is more in adults than children. In adults (15-44 years) all categories were slightly higher than in children (5-14 years) (7.04% versus 6.25%; odds ratio [OR] = 1.17, 95% CI: 1.037-1.215). It is found to be significantly higher in house-holds with one to fi ve members than in larger households (OR = 1.172, 95% CI: 0.91393-1.50432). The poor two quintiles (OR = 1.4598, 95% CI: 1.1386-1.8707) and illiterate group (OR = 1.2107, 95% CI: 0.87418-1.65278) and primary level of education (OR = 1.4336, 95% CI: 1.10874-1.84769) were more vulnerable to asthma attacks than the highincome group and more educated people, respectively. Conclusion Asthma has increased from 7 million people to 11 million over last 10 years although prevalence is almost similar. Introduction Secretory gVPLA2 is an inducible protein and an essential signaling molecule for airway infl ammation and airway hyperresponsiveness in immunosensitized and LPS-induced ALI in mice. However, identifi cation of secretory gVPLA2 in human airway diseases has not been identifi ed previously. Methods Donors were classifi ed as non-asthmatic, asthmatic, COPD or IPF from prior medical records. Identifi cation of gVPLA2 in airway microsections was quantifi ed by immunofl uorescence analysis. Expression of gVPLA2 in was analyzed using criteria for intensity scoring in a single-blinded method. In separate studies, airway smooth muscle cells (ASMC) obtained from asthmatic and non-asthmatic subjects (Regional Organ Bank of Illinois) were cultured within 24 h from death. Adhesion was assessed by measuring the eosinophil peroxidase activity of adherent eosinophils to ASMC. Inhibition of adhesion was assessed using neutralizing mAbs against surface adhesion molecules and mAb against gVPLA2. Results GVPLA2 was abundantly expressed in airway smooth muscle, epithelium and endothelium of patients with a history of asthma compared to non-asthmatic. Low expression of gVPLA2 was observed in tissues from COPD and IPF subjects. In cultured asthmatic ASMC, surface ICAM-1 and VCAM-1 also were upregulated. Activation of asthmatic ASMC with methacholine caused release of gVPLA2, which corresponded to augmented eosinophil adhesion; MCL-3G1, a mAb against gVPLA2, prevented these responses. Blockade of surface β1-/β2-integrin on eosinophils or its counter-ligands on ASMC blocked also the adhesion. Conclusion Our data demonstrated that gVPLA2 is highly expressed in asthmatic ASM but not in patients having, no history of asthma, COPD or IPF. GVPLA2 secreted from activated ASMC augments eosinophil adhesion; MCL-3G1 specifi cally blocked the cell-cell ligation. These data are the fi rst demonstration that the upregulated eosinophil adhesion to the surface of asthmatic ASMC is linked directly to the secretory gVPLA2. Based on our fi ndings, it is likely that the ASMC, which is the natural source of gVPLA2, regulates airway infl ammation and airway hyperreactivity, which are hallmarks of asthma. Supported by NIH grant HL-85779 and UK GSK Center of Excellence in Asthma.

Introduction Currently, there is still a lack of operational research analyzing the infl uence of an adequate TB curriculum in medical school. This study, aims to determine the effi ciency of integration of TB program into the medical school curriculum, measured through the knowledge, attitudes, and practices of medical clerks on TB. Methods A questionnaire-based survey on the knowledge, attitudes and practices on tuberculosis was conducted among medical clerks (fourth year medical students) in the UST Hospital. In total, 240 questionnaires were randomly distributed, of which 199 (83% response rate) of the questionnaires were returned fully accomplished. This was done over a period of one week. The questionnaire used was developed by Hong, et al 29; Huebner, et al 30; and Yu, et al 31. and modifi ed by the present authors. Results A total of 94.5% (n-188/199) of the clerks believed that sputum exam and culture are still the standard diagnostic modalities; quadruple therapy for 6-8 months as the standard treatment regimen. In total, 98.5% (n = 196/199) realized the magnitude of the problem of TB in the Philippines; half of them rated the Directly-Observed Therapy, Short Course (DOTS) program as good. In order to avoid infection, 94% wear masks, 47.7% keep their distance, and only 28.6% open windows. Only 12.6% would add two drugs to the current regimen of a patient with suspected drug resistance; while 37.2% responded with adding just one drug. Conclusion The integration of TB program in the curriculum of UST medical students is effective in enhancing knowledge and improving attitudes of the medical clerks. However, there is still a need to stress the importance of other practices aside from wearing masks in order to avoid infection, and to clarify issues on drug resistance.

The study was undertaken to assess the feasibility of diagnosing pulmonary tuberculosis (PTB) by collecting two sputum samples on a single day (1-day protocol) and to compare the same with the national policy of collecting two samples on consecutive days (2-day protocol). Methods Five hundred and thirteen individuals with cough exceeding 2 weeks were screened for pulmonary tuberculosis (PTB) by collecting three sputum samples, viz. day-1 spot sample, sample collected 1 hour after the fi rst sample and next day morning sample. For the 2-day protocol, performance of the fi rst and third samples were considered, while the 1-day protocol was evaluated using the two day-1 samples. Staining and microscopy were undertaken by two different technicians in a blinded manner. Results Out of 513 patients, 40 patients defaulted on second day. Of the total number of patients recruited, 124 (24.2%) were smear-positive. The 2-day protocol was capable of detecting 121 patients (97.6%), whereas in the 1-day protocol 118 patients (95.2%) were smear-positive (p = 0.3). Of the drop-out patients, 7 (17.5%) were smear-positive. Comparing the variation in results between spot and morning samples, collection of morning sample exhibited no signifi cant benefi t over the collection of a second spot sample. Conclusion Because the 2-day protocol does not lead to a statistically signifi cant diagnostic difference compared to the 1-day protocol, the latter can be adopted as an alternative protocol, particularly in subjects who are more likely to default. Introduction Tuberculosis, an important preventable and treatable cause of death, is a major health problem worldwide. Detecting patients with active pulmonary tuberculosis is an important component of tuberculosis control as early appropriate treatment renders these patients noninfectious and interrupts the chain of disease transmission. Sputum microscopy remains the test of choice as initial work-up for symptomatic patients with tuberculosis. However, in patients with a compatible clinical picture, sputum smears do not always reveal acid-fast bacilli. Patients symptomatic for tuberculosis but are found to be smear-negative are recommended to undergo further tests including fi beroptic bronchoscopy and sputum induction. The latter, however, is invasive and more costly. This study aims to compare the sensitivity and specifi city of sputum induction and bronchscopy in the diagnosis of sputum smear-negative tuberculosis by means of meta-analysis. Methods Computer search was done to obtain studies meeting inclusion criteria. The sensitivity, specifi city and other measures of accuracy were pooled using forest plots. Diagnostic odds ratios were obtained. Summary receiver operating characteristic curves were used to summarize overall test performance. Funnel plots and Egger regression analysis were used to examine for publication bias. Results Five prospective studies comparing diagnostic accuracy of fi beroptic bronchsocopy and sputum induction to diagnose sputum smear negative TB were obtained. The pooled summary indeces showed that for bronchial lavage, the sensitivity is 0.49 (95% CI, 0.42 to 0.59) while specifi city is 0.79 (95% CI, 0.75 to 0.84). Whereas for sputum induction, the sensitivity is 0.47 (95% CI, 0.40 to 0.54) and specifi city is 0.83 (95% CI, 0.79 to 0.87). The summary DOR for bronchial lavage was 3.27 (95% CI, 2.17 to 3.92) while the summary DOR for sputum induction was 429 meaning sputum induction test had a higher level of overall accuracy (95% CI, 291 to 634). Conclusion Sputum induction has comparable sensitivity and specifi city and higher level of overall accuracy compared to bronchial lavage in diagnosing for sputum smear negative tuberculosis.

Introduction Much of tuberculosis control is based on the current understanding of factors that infl uence transmission of Mycobacterium tuberculosis and that lead to active tuberculosis among persons who acquire the infection. One of these activities, contact investigation, is intended to identify persons who have acquired tuberculosis infection from a newly discovered active case, thereby enabling targeting of preventive treatment to a group at high risk of developing active tuberculosis, this being the main goal of activity. Methods The charts of close contacts of MDRTB patients enrolled in the Programmatic MDRTB Management of LCP PHDU from January 2008 to June 2009 was reviewed. Results There were 920 contacts of 244 culture and DST-confi rmed MDRTB patients identifi ed from January 2008 to June 2009. Among these contacts, 733 (78.8%) were traced and underwent evaluation and screening tests. Among the contacts >5 years old, 193 (23.83%) had a positive chest X-ray, 25 (3.95%) were AFB +, 18 (2.80%) were positive for MTB culture and sensitivity. In contacts <5 years old, 42 (38.2%) had positive chest X-ray results, but none had positive results on AFB smear, and MTB culture and sensitivity. Tuberculosis was identifi ed in 42 of contacts <5 years old and 75 of contacts >5 years old. There were 10 MDRTB cases identifi ed (8 confi rmed by culture and DST, and 2 treated empirically), all from contacts >5 years old. All Identifi ed MDRTB cases were treated with Category IV regimens under PMDT, while other TB (non-MDRTB) cases were managed under DOTS. Conclusion Contact tracing remains a helpful tool in public health programs at the Lung Center of the Philippines. Although the average contact per index is 3.8, 78.8% were successfully traced, which is comparable to other studies abroad. Among the screening tools, the chest X-ray was the most commonly utilized and also the most productive; AFB smear, tuberculin test, and MTB culture were performed in less than 15%. Among identifi ed contacts, MDRTB was noted in 1.57%. Introduction Active pulmonary tuberculosis (TB) requiring intensive care is rare but known to be of poor outcome. The present study aimed to describe the characteristics of patients with this condition and to identify the mortality rate and risk factors that predicts in-hospital mortality. Methods From January 2008 to December 2009, 55 patients were admitted to tuberculosis intensive care unit (TBICU) of Mackay Memorial Hospital, Taipei, Taiwan. Among these, 38 patients were enrolled and were followed up for 180 days. Incidence of in-hospital deaths was documented in the medical records and all possible parameters contributing to mortality were collected for analysis. Results The patients' median age was 73 years (range 28-90 years). The median length of intensive care unit stay was 15 days (range 2-172 days) and the median duration of mechanical ventilation was 13 days (range 0-172 days). Overall in-hospital mortality was 63% (24/38). Sepsis and shock were independently associated with in-hospital mortality. Conclusion These data indicated a high mortality of patients with active tuberculosis requiring intensive care, especially in those with sepsis and shock. Introduction We have shown that two commonly used prediction model s (VA and Mayo) estimate poorly the probability of malignancy of solitary pulmonary nodules (SPN) in the Philippines. This is due to a large proportion of SPN arising from tuberculosis (TB). In the Philippines, and possibly for other countries with a high TB-burden, our clinical prediction model has a better estimate to the probability of SPN than both the VA and Mayo. Methods We developed a prediction model to identify malignant lung nodules based on clinical data and radiographic characteristics among patients with SPN identifi ed retrospectively (October 2006 to March 2008) in our institution. Univariate and multiple logistic regression analysis were used to identify independent clinical variables. We applied the model to a new set of SPN patients (April 2008 and August 2008) and described its accuracy by comparing the predicted probability of malignancy with the fi nal diagnosis. We constructed receiver operating characteristic (ROC) curves and reported 95% confi dence interval. Calibration was done by dividing the sample into fi ve equal groups based on predicted probability and plotting the median probability of each quintile against the observed frequency of malignancy for that group. Results Seventy-six SPN patients were included in the development of the prediction model, where size, margin and smoking history were found significant in the multivariate analysis. Prevalence of malignancy was 33%. The area under the receiver operating characteristic (ROC) curve was 0.92; 95% confidence interval (CI) of 0.77-0.95. The equation was obtained based on the identifi ed predictors. Fifty-eight patients with SPN were included in the validation sample. Prevalence of malignancy was 36%. The ROC curve was 0.91; 95% C.I. of 0.85-0.97. Median predicted probabilities in all quintiles were lower than the observed frequency of malignant nodules, probably refl ective of the validation sample's higher prevalence of malignancy. Conclusion The local clinical model appeared to be suffi ciently accurate to inform clinical decisions about the choice and interpretation of subsequent diagnostic tests. The accuracy of the local clinical prediction model was similar to that reported in its development.

Introduction In a high-burden country for pulmonary tuberculosis like Philippines, it's not uncommon for intracthoracic masses be treated empirically with anti-tuberculosis regimen. We aim to describe patients' profi les, determine outcomes of empiric anti-tuberculosis treatment for such lesions. Methods We monitored patients with intrathoracic mass given empiric antituberculosis regimen until "end-of-treatment," decision to pursue diagnosis, or mortality. A 1-year prospective, observational, open-label, descriptive, cohort study, in a tertiary government hospital. Percentage association analysis was done at end of the study. Results In total, 20 patients presenting with intrathoracic mass lesions on chest X-ray/chest CT scan were treated empirically with anti-tuberculosis medicines without histopathologic evidence suggestive of pulmonary tuberculosis for the mass. Patients' choices, clinical and fi nancial status were factors considered by physicians in the decision for empiric treatment. There were 15 males, 5 females, with average age 47 years. Most common chief complaints were cough (50%), pain (20%), hemoptysis (15%), shortness of breath (15%). 11 patients had pulmonary consult within 3 months of initial radiography. Histology of mass was confi rmed within 3 months of pulmonary consult in 12 patients. 4 patients had the histopathology prior to starting empiric anti-TB treatment, which revealed non-specifi c fi ndings. A total of 16 patients were treated empirically prior to attempts for histologic diagnosis. Two of these patients never had diagnostics due to fi nancial constraints. While 14 patients went on to pursue histopathology, which revealed underlying malignancy in eight patients. Malignancy was seen more on males, older age (≥40 years), signifi cant smoking history, larger mass size (∼7-10 cm). Seven patients had clinical/radiographic improvement, two patients died, three were lost to follow-up. Conclusion Our study suggests no role for empiric anti-TB treatment for intrathoracic masses, even in a high-burden country like Philippines. We should vigorously pursue and search for defi nite histological diagnosis, as it will translate to cost-effectiveness, avoidance in delayed diagnosis, early institution of appropriate therapeutic management. We recommend further studies with larger sample size, to characterize patients' profi les, do subset analysis, identify who may need anti-tuberculosis treatment.

Introduction The use of viruses as targeted cancer therapy has shown signifi cant promise for novel anticancer therapy. Actually, a small number of enteroviruses, such as Coxsackievirus A (CVA) and Echovirus, have been reported to possess oncolytic activities against various human malignancies. However, a single intratumoral administration of CVA in vivo induces severe progressive muscle paralysis necessitating euthanasia of mice.

In this context, we discovered that Coxsackievirus B (CVB) displayed a high level of tropism and lytic activities for human lung cancer cell lines as a result of screening of representative 39 enteroviruses. CVB specifi cally destroyed both human non-small and small cell lung carcinoma via surface virus receptors of coxsackievirus and adenovirus receptor (CAR) at a multiplicity of infection (MOI) of 0.001, whereas it did not destroy normal lung cells at even a higher MOI of 10. The MTS cell proliferation assay also supported those results. Furthermore, our in vivo study showed that consecutive intratumor injections of CVB remarkably inhibited the growth of subcutaneously pre-established lung tumors, with signifi cantly more increased survival than untreated mice (P < 0.001). Surprisingly, in metastatic tumor mice model, intratumoral CVB injection into primary tumors in the right fl ank also signifi cantly retarded the growth of pre-established contra-lateral tumors compared with untreated mice. According to the results of fragmented PARP detection assay, the oncolytic effects of CVB against tumors could be partially attributed to their apoptosis as well as cellular degenerative destruction. Furthermore, fl ow cytometric analyses showed that CVB could possess an immuno-stimulatory ability through robust infi ltrated dendritic cells maturation in treated tumors. Moreover, none of mice died of CVB administration, suggesting the feasibility of clinical trials in the future, although analyses of serum biochemistry revealed moderate hepatic dysfunction due to CVB administration. Conclusion Our fi ndings suggest that intratumor CVB administration could be a novel therapeutic modality against not only primary human lung cancer but also metastasized lesions.

Introduction Radio frequency ablation (RFA) is a technique that employs high-energy radio frequency waves to destroy non-small cell lung cancer. The radio frequency ablation probe, Le-Veen multiple array needle electrodes, is placed inside a tumor and opened like a tiny umbrella with 10 curved prongs that spring into the surrounding tumor tissue. With this tool tumor cells are somewhat heated until they boil and become inert. Methods Patients with medically inoperable or unresectable single nodule NSCLC underwent treatments, in 3 different centers of Bangladesh. Multimodality treatment was mode of management. On the basis of intention to treat, patients were divided into fi ve groups for fi ve mode of treatment. Group 1: Percutaneous RFA (N = 120); Group 2: RFA followed by radiotherapy (N = 80); Group 3: Chemotherapy with RFA (N = 86); Group 4: Radiotherapy alone (N = 65); and Group5: Chemo radiation (N = 35) during 9-year period (2000-2009). Patients' characteristics, local recurrences and overall and disease-free survivals were compared. Results In total, 386 patients were selected for study since December 2000. Mean size of tumors were 5 ± 3.1 (range 2.3-8.2 cm). Follow-up range was from 2 to 52 months, median 23.5 months. Survival rate of Group 1: Only percutaneous RFA was 83% at 1 year, 63% at 2 years and 42% at 3 years; for Group 2: RFA and EBRT 96% at 6 months, 80.8% at 1 year, 62.4% at 2 years, and 51.1% at 3 years; Group3: Patients treated RFA with chemo therapy 80% at 1 year, 63% at 2 years and 52% at 3 years; Group 4: With radiotherapy alone 55% at 1 year, 33% at 2 years, and 20% at 3 years; for Group 5: Similar patients treated with chemoradiation 61% at 1 year, 45% at 2 years and 22% at 3 years. Irrespective of stages, patients with tumor size 5 cm (N = 25) had an average survival 17 ± 5 months. Local recurrence occurred in 2.8% having tumors size 5 cm. 19 developed pneumothorax and 35 had lung infections, 7 of them had fetal. A total of 24 patients died of co morbid diseases while 77 died of disease progression within 3 years following RFA and EBRT or chemotherapy or RFA alone. Conclusion The RFA followed by EBRT or RFA along with adjuvant or neo adjuvant chemotherapy for inoperable NSCLC has a relatively low rate of complications that are easily managed and above all survival has improved compared with other combination therapy, i.e. chemoradiation. NB: RFA plus chemotherapy was only applied in stage II and III. Introduction Patients with chronic or debilitating illness such as lung cancer usually accompanied by some form of emotional responses such as denial, anxiety, and depression. Clinician should be aware of these condition for better lung cancer management. Methods Hamilton rating scale for Anxiety and Depression questionnaire were administered to all patients diagnosed with lung cancer in dept Pulmonology-Respiratory Medicine University of Indonesia/Persahabatan Hospital consecutively. Follow-up evaluation will be done to evaluate anxiety/depression after a 3-month therapy. Results Among 30 lung cancer patients , 14 (46%) has anxiety, 12 patients (40%) has depression and all patients with depression also has anxiety. These conditions commonly found in male than female (10 out of 24 male patients (42%) vs. 2 out of 6 female patients (33%)). Further evaluation are underway to evaluate the degree of these disorders and other factors correlate with these disorder. Conclusion Depression and anxiety were also found in lung cancer patients and need further evaluation and attention from clinician.

To compare the preoperative classifi cation of lung carcinoma made on histological specimens by Fiberoptic bronchoscopy(FOB)with the postoperative classifi cation made on resected specimen and how often was used term of NSCLC. Methods We reviewed the records 116 patients who had a diagnosis ofthe lung cancer made by fi beroptic bronchoscopic biopsy (at Yedikule Chest Hospital, Istanbul in 2009) and who underwent a lung resection.Postoperative histological classifi cation were made according to the WHO classifi cation of the lung tumours. Results Fifty one of 84 squamous carcinoma, 1 of 13 adenocarsinoma and 8 of 9 carcinoid tumours were correctly typed with the small biopsy obtained by FOB. Forty eight patients who had a diagnosis of lung cancer established by fi breoptic bronchoscopy were labelled as NSCLC, 69%, 25% and 6% of them were classifi ed squamous carcinoma , adenocarcinoma and other tumour type respectively with examination of tissue obtained by surgical resection. Conclusion Accurate cell typing by specimens obtained at fi breoptic bronchoscopy may be extremely diffi cult.If clearcut morphological criteria can not be satisfi ed , the diagnosis of "lung cancer ,non-small cell" type should be made. Introduction The NSCLC patients who experienced good clinical responses even sometimes dramatic responses to EGFR-TKIs gefi tinib or erlotinib will inevitably develop acquired resistance. However, the clinical defi nition of acquired resistance is not clear. We investigated the clinical characteristics of acquired resistance to gefi tinib in NSCLC retrospectively. Methods We analyzed four hundred and forty NSCLC patients who had taken gefi tinib more than 6 months duration. All clinical data were obtained from 11 centers of Korean Molecular Lung Cancer Group (KMLCG). The timing, clinical manifestations, and the association of EGFR genotype were analyzed in the aspect of acquired resistance development.

The mean duration of gefi tinib prescription was 12.3 + 7.1 months. Signifi cant predominance in Female (63.2%) and non-smoker (68.9%) was noted. Among the patients who examined EGFR genotype, the mutation rate was 54.0 % (68/126), relatively lower than expectation. The relative ratio of local vs. systemic progression is 62.8%:38.2% and symptomatic progression rate is 63.8%. The survival time after the development of acquired resistance is 9.3 + 9.5 months. Conclusion These retrospectively analyzed clinical data for the development of acquired resistance to gefi tinib will help set up the clinical defi nition of acquired resistance to EGFR-TKI. Introduction Numerous studies have documented overall effectiveness and safety of chemical pleurodesis using variety of agents. Although reports regarding complications post-talc pleurodesis were minimal, concerns on the adverse effect profi les remains, especially on occurrences of serious and life threatening respiratory insuffi ciency and ARDS following talc pleurodesis. Methods Records of patients admitted at LCP who underwent talc pleurodesis from January 2008 to December 2009 were reviewed and all complications post pleurodesis were noted. Results A total of 96 charts of patients admitted at LCP who underwent pleurodesis from January 2008 to December 2009 were reviewed. The mean age was 57 ± 14 y/o with male predominance compared to female at 65 (67.7%) and 31 (32.3%) respectively. Of the total procedures evaluated, 43 (44.7%) involved all post procedure complications, 30 (31.25%) patients developed minor complications while 13 (13.54%) had major complications. There was no statistically signifi cant association noted with age, sex, smoking history, co-morbid illness, underlying disease, and method of pleurodesis, while chest tube drainage time more than 7 days was noted to be associated with greater incidence of major complications which was statistically signifi cant. Most common minor complications were fever (21.9%), followed by tachycardia (20.8%), chest pain (13.5%) and dyspnea (9.4%). The top 3 major complications were hypoxemia, hypotension and pneumonia. There were 2 (2.1%) patients who died post pleurodesis that is believed to be related to ARDS following talc slurry. Conclusion Talc pleurodesis is an effective agent for chemical pleurodesis but not without adverse effects. Cardiovascular complications are potentially avoidable by proper patient selection and preparation prior to talc pleurodesis. Respiratory failure and ARDS are rare but serious complications that should be promptly recognized and addressed rapidly and effectively.

Introduction Nebulized antibiotic is an established safe and effective therapy for bronchiectasis. Gentamicin are considered among the most useful classes of antibiotics for treating pseudomonas aeruginosa infections.The major drawback of aminoglycosides is the need for their relatively high dose intravenous administrations which carries the potential systemic toxicity.when gentamicin is given intravenously in maximum safe doses, only relatively low sputum concentration are achievable. These limitations can be circumvented by direct delivery of aerosolized antibiotic to the airways. Methods This study was carried out in NIDCH Dhaka. In total, 65 patients were taken initially for the study. Introduction Immune-modulator nutrition may decrease mortality among patients who are mechanically ventilated due to severe Community Acquired Pneumonia (CAP). Methods We compared an immuno-modulator nutrition and standard feeding formula to determine the effect on in-hospital mortality as well as 30 days mortality among mechanically ventilated patients due to severe CAP. The mean number of ventilator days, ICU stay, as well as clinical parameter (Clinical Pneumonia Infection Score (CPIS) and PaO 2 /FiO 2 ratio from Arterial Blood Gas) was also compared. In total, 38 eligible patients were randomized, double blind, to receive either immuno-modulator nutrition (Supportan SP) or standard feeding formula (SF). Follow-up was done on day 1, 4 and 7 on CPIS and PaO 2 /FiO 2 ratio. Results Primary outcome was mortality. No signifi cant difference noted between the two groups (p = 0.64; 95% CI: −0.18 to 0.28). The 30 day mortality on 32 patients revealed 2 patients (12.5%) died on SF group and 1 patient (6.25%) on SP group (p = 0.52; 95% CI: −0.14 to 0.28). The mean ventilator days on the SF group and SP group was 7.44 days and 5.47 days respectively (p = 0.15; 95% CI: −0.75 to 4.69), although not signifi cant, it suggests a trend favoring SP group. The mean ICU stay in the SP group was noted to be signifi cantly shorter (7.05 days) than in the SF group (10.84 days) (p = 0.04; 95% CI: 0.19 to 7.48). The CPIS and PaO 2 /FiO 2 ratio were done on day 1, 4 and 7. On day 1, the mean PaO 2 /FiO 2 ratio was still signifi cantly higher on the SP group (p = 0.0001; 95% CI: −93.54 to −36.79); while the mean CPIS was still the same with baseline (p = 0.43; 95% CI: −0.58 to 1.32). On day 4, no significant difference was noted (p = 0.63; 95% CI: −109.85 to 66.87 and p = 0.46; 95% CI: −1.26 to 2.18, respectively), as well as those on day 7 (p = 0.47; 95% CI: −81.71 to 168.05 and p = 0.47; 95% CI: −2.07 to 4.67, respectively). Conclusion We found no difference on mortality between SF and SP group. However, it suggests trend of earlier extubation and signifi cant shorter in ICU stay, in patients who received immuno-modulator nutrition.

Introduction Several equations to predict lung function of individuals of different population are available. However it is desirable that lung function laboratories use reference equations that most closely describe the population they test. The objective of the study was to develop a prediction equation for the Malaysian population. Methods Spirometry was performed on a total of 1483 "healthy", lifetime non smoker volunteers (386 males and 1097 females) All measurements met the ATS acceptability and reproducibility criteria. Prediction equations were derived for both men and women for FVC and FEV1. The equations were validated on a new group of subjects (n = 532, 222 males and 310 females) who met the same inclusion and exclusion criteria as the main cohort. Introduction Patients with severe asthma (experiencing previous hospital admissions and/or daily symptoms) have occasionally been seen with poor or weak complaints. Several studies have analyzed the psychiatric status of the patients with severe asthma, but few studies have The Japan Respiratory Society (JRS) has proposed new predicting scores, called the I-ROAD system for Hospital acquired pneumonia (HAP) in 2008. Depending on the presence of the parameters listed below, patients with HAP were stratifi ed into those with high, moderate or low-risk. The high-risk group was defi ned as patients with three or more of the following risk factors: 'malignant tumor or immunocompromised status', 'impaired consciousness', 'requiring fraction of inspired oxygen (FiO 2 ) > 35% to maintain SpO 2 > 90%', 'male aged 70 years or older, or female aged 75 years or older' and 'oliguria or dehydration'. The moderaterisk group was defi ned as patients with any of the secondary risk factors as follows: 'CRP ≥ 20 mg/dl' and 'extent of infi ltration on CXR covers at least 2/3 of one lung'. The low-risk group was defi ned as all other patients. The aim of this study was to confi rm whether I-ROAD is useful in predicting severity of CAP and HCAP. Methods All patients with an admission diagnosis of CAP and HCAP from January 2009-July 2009 were reviewed. Clinical and laboratory features at presentation in electrical medical records were used to calculate severity scores using the CURB-65 (2004), A-DROP (2005) and I-ROAD (2008). Results Consecutive 314 patients (53% CAP) of mean age 77.5 years were included in the analysis. Nineteen (11.7%) patients with CAP and seventeen (11.7%) patients with HCAP died. The ROC analysis for predicting mortality at 30 days showed that I-ROAD score has similar predictive accuracy for short-term mortality to CURB-65 and A-DROP in patients with CAP, but shortterm mortality of the patients with HCAP are not similar to them. Conclusion The JRS I-ROAD could be used to assess severity of CAP, and gives similar results to CURB-65 and A-DROP.

OS 08-05

Introduction Numerous asthma and COPD patients repeatedly return to hospital ED for urgent therapeutic care despite referral to their primary care provider. This study was aimed to identify these respective populations with frequent ED visits and assess the current therapeutic management of acute exacerbation of asthma and COPD at Hospital Kuala Lumpur, Malaysia. Methods The demographic and medical data was prospectively collected and recorded in March 2010 using convenient sampling, and then descriptively analyzed using SPSS version 16. Appropriate statistical analysis were applied with p < 0.05 was considered as signifi cant.

The study recruited 126 patients (male 51.6%) with 87.3% asthmatics and 12.7% COPD. Malays signifi cantly presented to ED the most (65.1%) followed by Indians (25.4%) and Chinese (7.1%). Most patients were between 17-64 years old (72.2%) with mean age of 41.5. About 17.5% were smokers (16.7% ex-smokers) with an average duration of smoking 26.73 years and 21.95 pack-years. For occupational data, 52.5% were belonging to non-professional group. About 85.5% asthma and 87.5% COPD patients had visited ED last year with average visit of 3.44 and 7.3 times and mean number of hospitalization was 1.68 and 1.33, per year, respectively. About 51.6% patients without scheduled appointments and 15.1% were not on any prescribed medications for asthma or COPD. Among patients with prescribed medications, 99.1% were on SABA and 66.4% on inhaled corticosteroids. Respiratory infections remained as main triggering factors of admission (43.7%), followed by weather (30.2%) and air pollution (5.6%). Average duration of treatment was about 50 minutes with mean direct therapy cost of RM15 per patient excluding the standard admission fee. Whil HR monitoring, the level of oxygen saturation and PEFR were signifi cantly improved post treatment. Oxygen-driven nebulised SABA and IV hydrocortisone were the mainstay of treatment. However, the use of an anticholinergic as a step up approach in nebulised treatment was underused. Most discharged patients were given oral SABA (87.3%) and prednisolone (88.1%). PEFR measurement was not practiced post treatment regularly. Conclusion Limited number of staff contributed towards omitted monitoring steps. Involvement of ED pharmacists in respective therapeutic management is highly suggested.

Introduction Fluid volume is an important factor when considering pleural drainage. However, there is limited literature regarding accurate quantifi cation of pleural effusion by ultrasonography. In a study by Visperas et al, they quantifi ed the pleural effusion volume by measuring the length, width, and depth of the fl uid, while the patient was in a sitting upright position, and the actual volume drained. They postulated a linear regression equation to quantify estimate the pleural fl uid volume that will be drained. 

Introduction Insomnia disorder is the most common sleep disorder which affected more than 18 300 000 people in Bangladesh. 7 600 000 people develop chronic insomnia disorder with symptoms of diffi culty falling asleep for more than 30 minutes and last for more than 1 month. Patients with insomnia disorder in Bangladesh took 2 900 000 sleeping pills each year for insomnia disorder. However, there were still some side effects about sleeping pills such as allergy, amnesia, hallucination etc. Because of the side-effects of modern medicine and because of the inability of modern medicine to cure insomnia disorder, international scientifi c interest has re-focused on the traditional uses of medicinal plants to fi nd effective cure for insomnia disorder as well as hundred of other disorders. A study of the traditional health practitioners in the Habiganj district of Bangladesh suggested that some of the herbal medicines prepared from medicinal plants might be quite effective for insomnia disorder. Methods Information was collected through a series of interviews with the traditional health practitioners, rural and urban people. Field notes were recorded on the medicinal plants and their uses; following the methodology of Bhat et al. (1990) and Martin (1995) . The identifi ed medicinal plant specimens were stored at the Bangladesh National Herbarium; under the author's collector series. Results The following medicinal plants or plant parts were found to be used as remedy for insomnia disorder: Cyrtandra cupulata Ridl., Bacopa monnieri (L.) Pennell, Ocimum gratissimum L., Lawsonia inermis L., Cinnamomum camphora (L.) Sieb., Aconitum napellus L., Datura metel L., Mimosa pudica L., Achyranthes aspera L., Piper betle L., Randia dumetorum (Retz.) Poir., Ficus glomerata Roxb., Nigella sativa L., Agaricus albolutescens Zeller, Ipomoea aquatica Forssk., Stephania japonica (Thunb.) Miers, Withania somnifera (L.) Duna, Cannabis sativa L., Calamus rotang L., Uraria picta (Jacq.) DC., Sesamum indicum L., Asparagus racemosus Willd., Abrus precatorius L., and Brassica napus L. Conclusion Information on indigenous use of medicinal plants has led to discovery of many medicines in use today. It is important that modern scientifi c studies be conducted on these medicinal plants towards isolation and identifi cation of compounds through which insomnia disorder can be effectively treated.

Introduction Existing data on the association between sleep duration and blood pressure in adolescents are inconsistent and confl icting. This study aims to determine the relationship between sleep duration and 24-hour ambulatory blood pressure in adolescents. Methods Subjects aged 10-17.9 years were recruited from the community. They underwent nocturnal polysomnography (PSG) and 24-hour ambulatory blood pressure monitoring (ABPM) on the same day. Daytime, nocturnal and 24-hour average systolic and diastolic blood pressure (SBP and DBP) were converted to z score with reference to height and gender according to normal reference. A 7-day sleep diary was completed prior to PSG. Daily sleep duration was defi ned as the average of nocturnal sleep duration plus the average of daytime nap duration over 1 week. Subjects with body mass index (BMI) greater than the 85th percentile of the local normal reference were classifi ed as overweight. Those who were overweight and had an obstructive apnoea hypopnoea index (OAHI) greater than or equal to 5 were excluded from the analysis. Results One hundred forty one subjects (86 boys) with a mean (SD) age of 14.3 (1.8) years were recruited. They were divided into 4 groups according to their daily sleep duration (<7.5 vs. 7.5-8.5 vs. 8.5-9.5 vs. > 9.5). Subjects with shorter sleep duration tended to have higher daytime SBP (p < 0.001), nocturnal SBP (p = 0.002) and 24-hour SBP (p < 0.001). Similar results were found after converting the BP data into z score (p = 0.005, 0. Introduction Some studies have shown decreased plasma and hair Zn in human asthmatics which may indicate a state of zinc defi ciency. We have shown, in a well characterized murine model of allergic airway infl ammation, that there were marked losses of Zinquin-stainable (labile) Zn in the infl amed airway epithelium (AE); when these mice were placed on low Zn diets, there was excessive cell death in the AE, and increased airway infl ammation. We have proposed that labile Zn protects the AE from premature cell death and loss of this Zn contributes to the AE fragility and infl ammation in asthma. A screen of whole lung gene expression of the two major families of ZIP infl ux transporters and ZnT effl ux transporters, indicated a marked loss of ZnT4 in the infl amed lungs. The hypotheses being tested here are 1) AE Zn is normally stored in vesicles within the apical cytoplasm, 2) ZnT4 is responsible for transporting Zn into these bodies and 3) loss of ZnT4 expression in asthma may result in a failure of Zn to be sequestered. Methods Human nasal epithelial brushings were obtained from healthy, consenting donors. Lung tissue was obtained from Balb/c mice sensitized and aerosol-challenged with ovalbumin or saline (Controls). Distributions of zinc were determined by Zinquin fl uorescence or in vivo selenite autometallography (Se-AMG). Distributions of ZnT4 were determined by immunofl uorescence. Results Zinquin fl uorescence of human and murine AE indicated abundant labile Zn with a vesicle-like pattern of staining in the apical cytoplasm. Se-AMG confi rmed the presence of apical Zn vesicles at an ultrastructural level. There was strong immunolabelling for ZnT4 in the same region. Furthermore, there was an almost complete loss of ZnT4 protein in the bronchial epithelium of mice with allergic airway infl ammation. Conclusion Colocalization of ZnT4 with labile Zn in AE may indicate a role for this zinc transporter in replenishing Zn storage pools in this tissue. Loss of ZnT4 protein during airway infl ammation would then result in failure to sequestrate Zn, depleting critical storage pools of Zn in the lung and airways, leading to increased AE damage and cell death. This work was supported by NHMRC Project Grant 519206.

Introduction Community-acquired pneumonia remains a major cause of mortality in developed countries. There is much discrepancy in the literature regarding factors infl uencing the outcome in the elderly population. Methods Data were derived from a multicentre prospective study initiated by the German Competence Network for Community-Acquired Pneumonia. Patients with community-acquired pneumonia (n = 4,647; 2,298 aged < 65 years and 2,349 aged ≥65 years) were evaluated, of whom 71.4% were hospitalised and 28.6% treated in the community. Clinical history, residence status, course of disease and antimicrobial treatment were prospectively documented. Microbiological investigations included cultures and PCR of respiratory samples and blood cultures. Factors related to mortality were included in multivariate analyses. Results The overall 30-day mortality was 6.6%. Elderly patients exhibited a signifi cantly higher mortality rate that was independently associated with the following: age; residence status; confusion, urea, respiratory frequency and blood pressure (CURB) score; comorbid conditions; and failure of initial therapy. Increasing age remained predictive of death in the elderly. Nursing home residents showed a four-fold increased mortality rate and an increased rate of gram-negative bacillary infections compared with patients dwelling in the community. Conclusion The CURB score and cerebrovascular disease were confi rmed as independent predictors of death in this subgroup. Age and residence status are independent risk factors for mortality after controlling for comorbid conditions and disease severity. Failure of initial therapy was the only modifi able prognostic factor. Introduction Hospital-acquired pneumonia (HAP) attributes to 15% of all nosocomial infections. Mortality rate is as high as 30-70%. Guidelines for the management of adults with HAP were recently updated. Despite the emergence of evidence-based medicine, the use of these guidelines in daily clinical practice is still limited. Currently, there is no literature published regarding the impact of adherence to the guidelines and clinical outcomes of HAP. Methods A total of 40 patients (Male: 50%; Female: 50%) admitted and diagnosed with HAP at our Center were followed up to investigate the rate of adherence of physicians on the diagnosis and treatment of HAP based on Level I and II ATS/IDSA 2008 recommendations and to determine its association with outcome (mortality, mechanical ventilation, ICU stay, hospital stay). Adherence to diagnostics and therapeutic management were computed per patient. Management of patients was classifi ed as adherent if it meets more than 70% of the guidelines that should be enforced. Results In this cohort, 55% of the physicians adhered to the currently recommended guidelines. Age, gender, and co-morbid conditions such as hypertension, diabetes mellitus, COPD, CKD and cerebrovascular disease were not statistically associated with the outcome of the study. A total of 30% of the subjects were eventually mechanically ventilated (p = 0.525). A total of 5% of patients who adhered to the recommendations consequently died during hospitalization (p = 0.073). Similarly, Univariate Analysis of Variance revealed that there is no signifi cant association of adherence to length of ICU stay and hospital stay (p = 0.807, 0.802 respectively). Of the level I and II current recommendations, request of Blood Culture showed signifi cant association with adherence (p = 0.045). However, Logistic regression analysis showed that there is no association of adherence in doing blood culture to mortality. Conclusion This analysis showed that compliance with the currently recommended ATS/IDSA recommendations is 55%. Blood Culture is the most signifi cantly associated recommendation. Rate of endotracheal intubation, length of ICU and hospital stay and mortality however was not signifi cantly associated with adherence. Introduction Reportedly high arsenic level in drinking water causes increased mortality and morbidity in adult COPD patients. Arsenic related health hazards include respiratory symptoms with decreased lung function added to skin lesion. Currently 70 million people of Bangladesh are at potential risk of consuming arsenic contaminated drinking water and a major section of them showed many symptoms including alteration of lung function. Methods The present study was conducted on chronic arsenicosis patients in selected areas of Bangladesh to assess lung function status by measuring FVC, FEV1, FEV1/ FVC% & PEFR. In total, 120 subjects of 20-50 years of age of both sexes were selected. 40 apparently healthy subjects were selected from non arsenic residency as well as not exposed to arsenic in their tube-well water and were grouped as healthy control. Of 80 subjects from area exposed to arsenic contaminated tube-well water, 40 were patients of chronic arsenicosis with skin lesions were considered as experimental group, whereas 40 subjects without skin lesions were regarded as exposed control. Results The mean measured values of the lung function parameters of nonarsenic exposed healthy control and exposed control were within normal ranges. But these values were signifi cantly lower in chronic arsenicosis patients with skin lesions. The parameters showed negative correlation with age, arsenic concentration in tube-well water but positive correlation with duration of the consumption. But these relationships were not statistically significant. All the patients of arsenocosis complained about respiratory symptoms in the morning. Conclusion The present study reveals that arsenicosis patients are suffering from respiratory insuffi ciency and symptomatic respiratory illnesses. In addition, populations consuming higher arsenic concentration in drinking water are at the risk of lung function impairment and ultimately may lead to respiratory disorders, though it would be better to draw a defi nite conclusion from a further study involving large sample size.

Introduction Despite of the detailed study of community-acquired pneumonia, the role of atypical microorganisms such as M. pneumoniae, C. pneumoniae and L. pneumophilla is not still defi ned. Also there are some discussions about role of the associations of these bacteria with the other so-called typical microorganisms as S. pneumoniae and H. infl uenzae as well as the place of the viral pathogens in community-acquired pneumonia ethiology structure. The aim of our research was to defi ne the etiology of the community-acquried pneumoniae in young adults (17-34 years, fi rst group) and to compare the results with the data gained in aged patients (<60 years, second group). Methods The 300 young and 300 aged patients with community-acquired pneumonia were screened with bacteriological, disk-diffusion with MIC, PCR and other methods. Antimicrobial agents resistance was checked to NCCLS standards and the clonality of the isolates was checked by PFGE and MLST for the most frequent clones. Results bacterial associations were defi ned in 55% versus 72% in the second group. M. pneumoniae was identifi ed in 39% vs 19%, C. pneumoniae 33.4% vs 24%. The bacterial pathogens were represented with the species S. pneumoniae (58.44%/42%), H. infl uenzae (15.06%/21%), M. catarrhalis (26.23%/7%). Among the viral pathogens the most often was metapneumovirus in young adults (23%), and infl uenzae virus in aged patients (18%). The most prevalence bacteria were genotyped and there were revealed the relations between several isolates of M. pneumoniae and S. pneumoniae existing as association in several cases of different age groups what proved the epidemiological character of the spread of this association. So, the most frequent clone of S. pneumoniae was recognized as ST156, as well as ST214. PFGE typing of atypical microorganisms also revealed the spread of the several clones. Conclusion some changes in etiology structure of community-acquired pneumonia seems to be connected with the changes in immunology peculiarities of different age groups, as well as with the other epidemiology reasons.

Introduction Despite of the detailed study, the role of Acinetobacter baumanii pathogen as the a ubiquitous opportunistic nosocomial pathogen is still appreciated. The most of epidemiological aspects of this infection are still discussed though the problem of the microbiology charecteristics of this pathogen are of keen microbiology interest. It is often isolated in immunocompromised hosts in different forms of hospital-acquired infections, but more often it was recognized as the main pathogen agent of hospital-acquired pneumonia. The aim of our research was to establish clinical signifi cance of A. baumanii in development of hospital-acquired pneumonia, to defi ne its epidemiology and to characterize antimicrobial agents resistance pattern. Methods We made 1-year surveillance of all hospital-acquired pneumonias (HAP) in adult patients in the main clinics of Vladivostok (Hospital Ð1, Ð2), defi ned etiology with standard microbiology methods. All isolates of A. baumanii were tested for antimicrobial agents resistabce according to NCCLS. The strains with the same antimicrobial agents resistance pattern were checked to clonality by pulsed-fi eld gel electrophoresis (PFGE). Results During 2008-2009, we studied all cases of HAP in 450 adult patients (<60 years) admitted to ICU and revealed that A. baumanii has taken the second place in etiology structure (19.1%, 94 cultures from 86 patients). The fi rst place was in Pseudomonas aeruginosa (29.3%, 132 strains) and the third one was in Stenotrophomonas maplthophila (11.7%, 53 strains). Mostly (58 strains, 61.7%), A. baumanii was isolated as monoinfection, but in other cases it was isolated in association with another strains of A. baumanii, or P. aeruginosae, S. palthophila, S. aureus, E. feacalis, E. cloaceae. There were defi ned lower resistance to ciprofl oxacin. The clonality research revealed about 8 genotype clusters what could allow to suggest the genetic relatedness of the isolates. Conclusion Acinetobacter baumanii should be studied to defi ne the role in hospital-acquired infections, as well as it confi rms the fact that the importance of local surveillance programs in correctly guiding empiric therapy and local intervention programs in attempt to reduce antimicrobial resistance.

Introduction Community Acquired Pneumonia (CAP) is the most common cause of death associated with infectious disease. Locally, it is the leading cause of morbidity and the fi fth cause of mortality according to the Department of Health. The initial management decision after diagnosis is to determine the site of care: outpatient, hospitalization in a medical ward, or admission to an ICU. The decision to admit the patient is the most costly issue in the management of CAP, because the cost of inpatient care for pneumonia is up to 25 times greater than that of outpatient care. It is a well documented fact that signifi cant variation in admission rates among hospitals and among individual physicians occurs. Physicians often overestimate severity and hospitalize a signifi cant number of patients at low risk for death. Because of these issues, interest in objective site-of-care criteria has led to attempts by a number of groups to develop such criteria. The two foremost criteria are the British Thoracic Society criteria (CURB-65) and the Pneumonia Severity Index (PSI). The IDSA/ATS committee preferred the CURB-65 criteria because of ease of use and because they were designed to measure illness severity more than the likelihood of mortality. Patients with a CURB-65 score > 2 are not only at increased risk of death but also are likely to have clinically important physiologic derangements requiring active intervention. These patients should usually be considered for hospitalization. Therefore, the study was done to determine and compare mortality rates of the admitted cases of Community Acquired Pneumonia assessed by either CURB-65 criteria or the Philippine Clinical Practice Guidelines on CAP, and to determine the applicability of CURB-65 as a site-of-care tool in the admission of patients with Community Acquired Pneumonia either at the Wards or the Intensive Care Unit. Methods All patients seen at the Emergency Room and Out-Patient Department with the diagnosis of Community Acquired Pneumonia were included in the study. Thorough history-taking and physical examination was taken by the ER/OPD fellow whom would determine if the patient has pneumonia. Subsequently, laboratories (CXR, CBC, BUN, ABG) was requested. Randomization was done for severity assessment: One group was assessed via the CURB-65 criteria, while the other group was assessed using the Philippine Clinical Practice Guidelines for CAP. Severity assessment was done by the ER fellow together with the investigator not more than one hour of the patient's arrival at the ER/OPD. Patient was followed-up by the investigator within 24 hours of admission (ward or ICU) and until discharge or death. Results A total of 206 patients diagnosed with Community Acquired Pneumonia (CAP) were included in the study. The age range for the CURB group is from 18 to 100 years of age with a mean age of 62.33 ± 18.25 years, while in the CPG group, 16 to 97 years of age with a mean age of 57.20 ± 20.85 years. No significant difference were noted (p = 0.564). No signifi cant difference were also noted in the gender of both groups (p = 0.889). There was a signifi cant difference noted in the presence of comorbidities (p = 0.001) between the two groups, 70.9% and 47.6%, CURB group and CPG group, respectively. The presence of previous PTB treatment, Cardiovascular disease and COPD, ranks as the three most common comorbidity. Dyspnea (94.7%), cough (85%) and fever (72.3%) were the three most common symptoms noted. There were no signifi cant difference noted in these symptoms (p = 1.00, 0.697, 1.00, respectively). With regards to the physical fi ndings: crackles (89.3%), tachypnea (44.7%), wheezes (22.3%) were the three most common signs noted. No signifi cant difference were noted in most of the signs, except for "tachypnea" and "hypotension" (p = 0.000, 0.0007, respectively). There were no signifi cant difference in the radiographic fi ndings between both groups. No signifi cant difference were also noted in the complete blood count results be it leukocytosis (p = 0.314), anemia (p = 0.477) and leukopenia (p = 1.00). There is a signifi cant difference in the Blood Urea Nitrogen (p = 0.00002). No signifi cant difference was also noted in the arterial blood gas result: hypoxemia (p = 0.109) and hypercapnia (p = 0.499). For the CURB-65 group, more than half of the population was assessed to have a score of 2 (In-patient), 54 (52.4%). For the CPG group, more than half was assessed to be under the Moderate risk, 58 (56.3%). All of the patients assessed in the lower severity class, either thru the CURB-65 or the CPG, had been discharged improved. The overall mortality rate per group was: 5.8% for the CURB-65 group, 6 out of the 103 patients, and 1.9% for the CPG group, 2 out of the 103 patients. Mortalities were noted only on those with higher severity ratings. On further determination of mortality rate per level of severity, it revealed that those with a CURB-65 score of ≥3 has a mortality rate of 28.6% (6 out of the 21 patients), while those on the CPG, 22.2% (2 out of the 9 patients). Conclusion In this study, we determined that all of the mortality came from the higher severity levels: CURB-65 score ≥ 3 (28.6%), CPG-High risk (22.2%), none from the lower severity ratings The CURB-65 criteria is a useful site-of-care tool, though, the usage of CURB-65 criteria does not offer additional benefi ts compared to the use of the CPG, in fact because of familiarity of physicians with the latter, they are more adept in using it. Introduction Acute exacerbation has been a major complication of interstitial lung disease (ILD). The rapid recognition of a bacterial pneumonia and an acute exacerbation of underlying ILD appears to be clinically important for proper treatment. Procalcitonin (PCT), a precursor peptide of the hormone calcitonin is commonly detected at elevated levels under bacterial infection conditions. This study was to assess whether or not serum procalcitonin levels were useful as a biomarker for the differential diagnosis of ILD exacerbation from bacterial pneumonia. Methods We had planned a prospective observational study. Our study enrolled 21 ILD patients who had presented with recently progressive dyspnea, and newly infi ltrates of the chest in underlying ILD. Results Nine of them evidenced bacterial pneumonia with high PCT level. Serum PCT levels in ILD exacerbation group were signifi cantly lower than in the pulmonary infection group (the mean value 0.05 ng/ml vs 0.91 ng/ml, 95% [CI]). Sensitivity, specifi city, and negative predictive value of serum PCT level were 88.9%, 100%, 92.3% respectively. Conclusion The fi ndings of this study suggest that serum PCT value is useful in the differential diagnosis of bacterial pneumonia from exacerbation in patients with interstitial lung disease.

Introduction It has been well confi rmed that malnutrition and muscle wasting are important extra-pulmonary manifestations of chronic obstructive pulmonary disease (COPD), which are recognized as contributing to an increase in morbidity and decrease in quality of life. Myostatin, a transforming growth factorbeta superfamily member, is mainly expressed in skeletal muscle and has been characterized as a negative regulator of skeletal muscle mass. Studies have showed that myostatin is implicated in several diseases involved in muscle wasting and cachexia. Recently, there is evidence of myostatin secretion and circulation in animals and human blood, and more recently, studies have shown that intramuscular myostatin expression accelerated in COPD patients; while levels of circulating myostatin in COPD remain unclear. We therefore analyzed serum myostatin levels to investigate the relationship between circulating myostain levels and nutritional depletion and muscle wasting in COPD; and the relationship between circulating myostain levels and systemic cytokines such as tumor necrosis factor (TNF)-α and interleukin (IL)-6 in COPD. Methods Fifty-four male patients with stable COPD and twenty-one agematched, healthy, male control subjects participated in the study. Total-body skeletal muscle mass (SMM) were calculated according to a validated formula by using body weight, height and age. Nutritional status was evaluated by anthropometric measurements and serum protein levels; the former included body mass index (BMI), triceps skin-fold thickness (TSF) and mid-upper arm circumference (MAC), and the latter included serum prealbumin, transferrin and albumin. Serum levels of myostatin, TNF-α and IL-6 were detected by ELISA. Results Out of the patients with COPD, 38 ones (59.25%) had malnutrition, with BMI less than 21 kg/m 2 . Serum levels of myostatin were signifi cantly elevated in COPD patients compared with controls (11.51 ± 4.99 ng/ml vs. 6.97 ± 1.70 ng/ml, p < 0.01), and the levels were even much higher in those with malnutrition (12.31 ± 5.34 ng/ml). However, SMM was signifi cantly decreased in COPD patients compared with controls (20.66 ± 2.44 kg vs. 24.95 ± 2.35 kg, p < 0.01). All the nutritional parameters except of prealbumin were signifi cantly decreased in COPD patients compared with controls, with each p < 0.05. There is an inverse correlation between myostatin levels and SMM (r = −0.437, p = 0.001) and a positive correlation between myostatin and TNF-α levels (r = 0.317, p = 0.019) in COPD group, but no correlation between myostatin levels and serum proteins concentrations. Conclusion This study demonstrates that circulating myostatin levels were elevated in patients with COPD and that the elevated myostatin levels are closely related with malnutrition and muscle wasting in patients with COPD.

Introduction Chronic obstructive pulmonary disease (COPD) is defi ned by airfl ow limitation that is not fully reversible and no medication exists that clearly improves the mortality. Oxidative molecules, in particular superoxide anion, are believed to play an important role in COPD-associated abnormal infl ammatory response due to increase in the level of pro-infl ammatory cytokines and chemokines and pulmonary emphysema due to proteases/antiproteases imbalance and apoptosis. Superoxide dismutase (SOD) catalyses the dismutation of superoxide anion to hydrogen peroxide, which is subsequently detoxifi ed to oxygen and water. Lecithinized SOD (PC-SOD) has overcome a number of previous clinical limitations of SOD, including low tissue affi nity and low stability in plasma. In this study, we examine the effect of PC-SOD on elastase-or cigarette smoke-induced pulmonary emphysema, animal models for COPD. Methods Severity of pulmonary emphysema in mice was assessed by various methods, such as the number of leucocytes (neutrophils, lymphocytes and alveolar macrophages) in bronchoalveolar lavage fl uid (BALF) and enlargement of airspace (increase in mean linear intercept). Lung mechanics were assessed by a computer-controlled ventilator. The pulmonary level of superoxide anion was estimated by electron spin resonance analysis and the level of 8-hydroxy-2′-deoxyguanosine. Results Not only intravenous administration but also inhalation of PC-SOD suppressed elastase-induced pulmonary emphysema and dysfunction. Inhalation of PC-SOD showed therapeutic effect against elastase-induced pulmonary emphysema and dysfunction even when it administered after the development of emphysema. Inhalation of PC-SOD suppressed elastase-induced increase in the pulmonary level of superoxide anion and apoptosis. Inhalation of PC-SOD also suppressed elastase-dependent activation of proteases and induction of expression of pro-infl ammatory cytokines and chemokines. We also found that inhalation of PC-SOD suppressed cigarette smoke-induced pulmonary emphysema and dysfunction. Conclusion Results suggest that PC-SOD protects against pulmonary emphysema through decreasing the pulmonary level of superoxide anion and resulting inhibition of infl ammation, apoptosis and activation of proteases. We propose that inhalation of PC-SOD is therapeutically benefi cial for COPD.

Introduction Tiotropium is a recently developed inhaled anticholinergic in the management of COPD, exhibiting a prolonged duration of action and a kinetic selectivity to specifi c muscarinic receptors, leading to a more effective bronchodilator response at once-daily dosing. We determined the effi cacy of long-term tiotropium use on clinical endpoints such as mortality, exacerbations, and hospitalizations compared to inhaled long-acting beta-2 agonists among patients with COPD. Methods Search Methods RCTs were identifi ed from electronic databases. Bibliographies and relevant reviews were also searched. The date of the last search is August 27, 2009. Selection Criteria RCTs among patients with COPD comparing tiotropium monotherapy with inhaled LABAs with at least 6 months follow-up were selected for inclusion. Data on all-cause mortality, mortality from pulmonary causes, mortality from cardiovascular causes, rates of hospitalizations and exacerbations were identifi ed. Data Collection and Analysis Three investigators evaluated and extracted relevant data. Any disagreements were discussed and consensus decisions were made. The data were analyzed using RevMan 5. Studies were pooled to yield odds ratios and were reported using 95% confi dence intervals. Results From 27 RCTs, 3 clinical trials with a total of 2,552 patients met inclusion criteria. Tiotropium did not reduce the odds of all-cause mortality (OR 0.48 95% CI 0.06 to 3.58) compared to inhaled LABAs. Subgroup analysis also shows that tiotropium did not reduce the odds of mortality from pulmonary causes (OR 0.63 95% CI 0.24 to 1.64) but shows a trend that might increase mortality from cardiovascular causes (OR 2.17 95% CI 1 to 4.71). Tiotropium reduced the odds of hospitalizations from all causes (OR 0.75 95% CI 0.56 to 0.99) and showed a trend towards benefi t in reducing the odds of exacerbations (OR 0.88 95% CI 0.75 to 1.04). Conclusion Tiotropium did not reduce all-cause mortality among patients with COPD compared to inhaled LABAs, although it showed a possible trend towards harm in causing cardiovascular mortality. It also reduced hospitalizations, although it did not decrease the odds of exacerbations among patients with COPD.

Background Patients from Asia may have different outcomes compared to those from other backgrounds. We therefore examined outcomes in the subgroup of Asian patients in the UPLIFT trial. . More patients will be recruited until August 2010 in Vietnam and Singapore as well as in the above nine countries. This abstract contains an interim analysis.

The recruited patients were mostly male (93.6%) and elderly (mean age, 69.3 years). According to GOLD criteria, severity of airfl ow limitation was mild in 13.2% of patients; moderate in 44.0%; severe in 33.2%; very severe in 9.5%. A total of 92.7% of patients were exposed to cigarette smoking; 56.8% to dusty jobs. A total of 29.3% of patients had symptoms of "chronic bronchitis -phenotype" viz. chronic cough with phlegm; 58.0% had wheezing in the last 12 months. A total of 89.0% of patients were on regular medications, e.g. inhaled steroid combined with long-acting beta-agonist, theophylline, shortacting beta-agonist, tiotropium, combined inhaler of salbutamol and ipratropium, and inhaled steroid alone, in decreasing order. In the past one year, 45.9% patients required/ were prescribed antibiotics for acute exacerbations and 31.1 % required/were prescribed oral steroids. Of this cohort, 26% patients had unscheduled/ emergency visits to the ER or were hospitalized. Conclusion This interim report showed that Asian COPD patients are heterogeneous. A high proportion was exposed to dusty environments at their job sites and many were cigarette smokers. Further studies are ongoing to fi nd out other characteristics of COPD phenotypes including the infl uence of dusty job environment in the development and progression of COPD in Asia.

Introduction It is widely recognized that COPD is not only a lung-based disease, but also a systemic disorder with systemic infl ammation, which further aggravates the disease progression at acute exasperation (AECOPD). It is important to fi nd a systemic biomarker which is lung-specifi c and can be used to indicate the severity of the disease in the stable state (SCOPD) and at exacerbation. C reactive protein (CRP) and tumor necrosis factor (TNF)-a have been attracted attention as they can refl ect the systemic burden of infl ammation, while they are not lung-specifi c. Surfactant protein D (SPD) is produced and secreted by alveolar type II epithelial cells and Clara cells. Recently study has reported that SPD can be used to track disease progression and predict clinical outcomes in COPD. The present study was aimed to determine the value of SPD as a biomarker of systemic infl ammation in staging the severity of COPD and diagnosis of the exacerbation. Methods We recruited three groups of subjects: patients experiencing AECOPD (n = 38), patients with SCOPD (n = 71) and controls with normal lung function (n = 60). ELISA was used to analyze serum SPD, CRP and TNF-a levels. The BODE scoring system was employed to evaluate health status of patients with COPD, which included the four variables: body mass index, degree of airfl ow obstruction, dyspnea and exercise capacity. Conclusion The present study confi rms that circulating SPD levels are higher in COPD and closely related with health status of the patients and severity of the disease; moreover, circulating SPD can be regarded as a valid biomarker of systemic infl ammation and a potential diagnostic biomarker for AECOPD. Methods We reviewed all the records of bronchoscopies in our hospital from February 1, 2007 to January 31, 2010 and identifi ed 288 patients diagnosed subsequently with primary lung cancer whose sputum cytology was negative or not performed prior to bronchoscopy. A total of 26 patients with pulmonary tuberculosis were also identifi ed whose prebronchoscopic sputum acid-fast stains were negative or not performed. We reviewed the result of pathological examination of bronchoscopic specimens and postbronchoscopic sputum for the lung cancer patients and the result of mycobacterial culture of these specimens for the tuberculosis patients.

Of the 288 lung cancer patients, postbronchoscopic sputum cytology was performed in 238 patients and gave a positive result in 35 (14.7%) patients. The postbronchoscopic sputum was the only diagnostic specimen in 4 (1.7%) patients. Meanwhile, postbronchoscopic sputum culture was performed in 20 of the 26 tuberculosis patients and was positive for M. tuberculosis in 10 (50%) patients. Of these 10 patients, the culture of specimens obtained by bronchoscopy was negative in 5 patients, 3 of whom also had a negative result of prebronchoscopic sputum culture. Conclusion Postbronchoscopic sputum cytology has a limited role for the diagnosis of primary lung cancer and should not be performed in terms of cost-effectiveness. But its culture seems to provide additional information for the diagnosis of pulmonary tuberculosis and further studies are needed to determine when to obtain postbronchoscopic sputum specimens. for other malignant tumours -in 3 (2.1%) patients. In 13 (8.5%) patients with benign pathology 26 procedures were performed for tracheomalacia -in 3 (23.1%), for tracheobronchial fi stula -in 3 (23.1%), for endobronchial lipoma -in 1 (7.7%) and for other pathology -in 6 (46.1%) patients. There were 94 (54.7%) unilateral, 32 (18.6%) -tracheal, 31 (18.0%) -tracheobronchial and 15 (8.7%) -bilateral bronchial procedures. On 71 (41.3%) occasions procedure was elective, on 95 (55.2%) -urgent and 6 (3.5%) times it was performed as an emergency. Eight patients required stent replacement. Stenting was performed under general anaesthesia using combination of rigid and fi beroptic bronchoscopy and in majority with intraoperative X-ray control. Uncovered and covered Ultrafl ex stents (Boston Scientifi c) have been mainly used. Results There was no intra-operative mortality. Eleven (7.9%) patients died in hospital prior to discharge and 6 of them died within 24 hours after procedure. In all these patients urgent or emergency stenting was performed. Tumour debulking and/or cryotherapy were required on 52 occasions after stenting. Hospital stay ranged from 1 to 32 (mean -4.47, median -3) days.

In benign group there was one hospital death in a patient with TB stricture. In patients with malignant tumours total survival ranged from 1 to 1678 (mean -138.23, median -55) days, in elective subgroup -from 6 to 1678 (mean -180.16, median -56) and in urgent subgroup -from 1 to 1146 (mean -103.98, median -49) days. All patients had signifi cant improvement of distressing symptoms. Conclusion Tracheobronchial stenting is rapid and effective technique of palliation in patients with malignant or in selected cases of benign tracheobronchial stenosis. It provides better outcome if performed electively. Stent occlusion may be controlled by endobronchial cryotherapy. Introduction In the clinical evaluation of airway disease, fi beroptic bronchosopy (FOB) is a crucial tool in the diagnosis. However it is invasive, time-consuming and requires sedation. Endobronchial lesions may be seen in both fi beroptic bronchoscopy and MDCT virtual bronchoscopy (VB). The extensive image data acquired with VB permits the simulation of the internal as well as external appearance of the tracheobronchial tree. The objective of the study is to compare MDCT Virtual Bronchoscopy with Fiberoptic Bronchoscopy in the detection and characterization of tracheobronchial (airway) pathology, particularly to determine the overall agreement in the fi ndings in both modalities. Methods Patients who underwent CT Scan of the chest and then underwent fi beroptic bronchoscopy were included in the study. Each patient was assessed into 5 levels: trachea, carina, right mainstem bronchus, left mainstem bronchus, tracheobronchial branches. These levels were examined using virtual bronchoscopy for presence/absence of obstructive, endoluminal and mucosal lesions and compared with the actual fi beroptic fi ndings. The sensitivity and specifi city, PPV and NPV of VB were determined with FOB as the gold standard. Results A total of 13 patients were included in the study. Sixty-fi ve (N = 13; 5 levels) levels were observed, of which 48/65 (74%) accounted for the same evaluation using FOB and that of the VB. The sensitivity of VB in diagnosing endoluminal lesion was noted to be 40%, with specifi city of 95%. Virtual bronchoscopy overestimated obstructive lesions with two false positive results and detected two false negative patients with endoluminal mass. None of the mucosal abnormalities (mucosal erythema, edema, etc.) are detected using VB. Conclusion Virtual bronchoscopy may be comparable with fi beroptic bronchoscopy in the localization, morphologic description of tracheobronchial lesions. However, it has limited capability to reconstruct subtle mucosal irregularities. Consequently, it is prone to artifactual reconstruction for mucosal changes that may render a false positive fi nding. Overall, virtual bronchoscopy best complements the fi beroptic bronchoscopy in thorough evaluation of the tracheobronchial pathologies and cannot obviate the need for this invasive approach in the diagnosis of early mucosal changes within the airway. Results Of 20 patients 16 (80%) were male. All patients had multiple comorbidities which include Severe COPD = 13(65%), 12 (60%) patients each had heart failure, respiratory failure and anaemia,Hypoalbuminemia = 14(70%), active tuberculosis = 8(40%), PAH = 4(20%), CAD, CRF, CLD in 3 patients and age > 65 years was in 16 (80%) patients. All patients underwent CT thorax and FOB and after localizing bleed underwent BAE within 72 h of admission. In 3/20 (15%), BAE could not be done on account of technical reasons. Immediate control of bleeding was achieved in 17/20 patients (85%). In total, 15/17 patients (88.2%) reported no rebleed till 24 months. None developed early rebleed (<1 month) while 2/17 (11.7%) develop late rebleed (>6 months). One managed conservatively and other underwent lobectomy. Only complication of BAE was transient dysphagia in 1/17 (5.8%). Conclusion BAE is safe and effective in immediate and long term control of massive haemoptysis in elderly patients with multiple comorbidities and should be considered even in such high risk group.

Introduction Histologic specimens obtained by endobronchial ultrasoundguided transbronchial needle aspiration (EBUS-TBNA) often provide valuable information for diagnosis or management decisions. Besides the conventional 22-gauge needle, a 21-gauge needle is now available for this procedure. The purpose of the present study was to compare the histologic specimen retrieval yields of EBUS-TBNA using 21-gauge and 22-gauge needles for sampling hilar/mediastinal lesions. Methods Sixty patients with hilar/mediastinal lymphadenopathy or a tumor adjacent to the central airway were enrolled in this study and randomized to undergo EBUS-TBNA using a 21-or 22-gauge needle. Each histologic specimen obtained by EBUS-TBNA on the initial two punctures of each patient (total 120 punctures) was interpreted separately and categorized by an experienced pathologist as follows: I, diagnostic; II, nondiagnostic but adequate (e.g. lymphoid tissue); III, nondiagnostic and inadequate (e.g. clot); and IV, no specimens.

Results Median targeted lesion size in shortest diameter on CT in the group using a 21-gauge needle and a 22-gauge needle was 23.5 mm and 21 mm, respectively. Prevalence of malignancy on primary disease in each group was 77% and 83%, respectively. The specimens obtained by 21-gauge needle were interpreted as I in 35, II in 8, III in 15 and IV in 2. The specimens obtained by 22-gauge needle were judged to be I in 34, II in 13, III in 7 and IV in 6. The sampling yield of adequate histologic specimens (I and II) obtained by the 21-and 22-gauge needle was 72% and 78% (P = 0.4). No complications were associated with the procedures. Conclusion Histologic specimens can be obtained with a high sampling yield by either of the needles. Our study could not show any difference in sampling yield between the two needles. Introduction Diagnostic Tuberculosis using Acid fast bacilli (AFB) microscopy and conventional Lowenstein Jensen (LJ) culture remain the cornerstone but the sensitivity of these traditional methods is quite low, especially in the samples containing small number of organism. There is a need for rapid, sensitive and accurate detection of these organisms in clinical specimens to hasten the administration of appropriate antimycobacterial therapy and prevent the spread of infection in the community. Sputum smear-negative pulmonary tuberculosis (SSN-PTB) is a common problem faced by clinicians. Performing fi ber optic bronchoscopy (FOB) and subjecting the bronchoalveolar lavage (BAL) material to diagnostic methods of smear and mycobacterial culture appears to be helpful in the diagnosis of SSN-PTB. 

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Longer term follow up of aerobic capacity in children affected by severe acute respiratory syndrome (SARS)

The usefulness of virtual bronchoscopic navigation has been established for the diagnosis of small peripheral lesions. Exclusive software (Bf-NAVI) from Olympus Medical Systems is commercially available, but because no function to display extra-airway structures has been installed, this could not be indicated for testing where the purpose is mediastinal/hilar lymph node aspiration. Using an improved version of the software from Olympus Medical Systems to permit lymph node visualization, this study evaluated the aspiration support function. Methods Before testing, size and position of lymph nodes for aspiration were established on MPR images of CT data. On the virtual navigation image, these were displayed in a transparent ellipse from the airway. Besides rotation and back and forth movements, changes in angle of the bronchoscope tip are simulated, and a function is also available to move the virtual image fi eld up, down, left, and right. Using these, the navigation image was compared with the real image, and the lymph nodes were aspirated. In 8 patients with enlarged mediastinal/hilar lymph nodes, transbronchial needle aspiration (TBNA) without using an ultrasound probe, or EBUS-TBNA, was selected for aspiration. Results Lymph nodes were aspirated under navigation in all patients. The diagnosis was primary lung cancer in fi ve patients, metastatic tumor in one patient, and sarcoidosis in two patients. Depth perception was diffi cult for the transparently displayed lymph nodes, particularly #2 and #4, and judging anterior-posterior relationships was diffi cult when nodes were superimposed. Conclusion Some room for improvement thus remains in the display method. However, this offers future promise as diagnostic support technology.