Showing papers in "Respirology in 2005"

Global Initiative for Chronic Obstructive Lung Disease strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: An Asia-Pacific perspective

Abstract: Correspondence: Wan C Tan, Department of Medicine, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074, Republic of Singapore. Email: wtan@mrl.ubc.ca Received 21 February 2004; revised 16 September 2004; accepted for publication 17 September 2004. *Members of the COPD Roundtable Group and countries represented within the Group include Prof Wan Cheng Tan (GOLD implementation committee member, Singapore), Dr Aziah Ahmad Mahayiddin (Malaysia), Prof Suchai Charoenratanakul (Thailand), Prof Zhong Nan Shan (China), Prof Paul Seale (Australia), Prof Mary Ip (Hong Kong), Dr Teresita de Guia (Philippines), Prof Young-Soo Shim (Korea), Prof Chi-Huei Chiang (Taiwan) and Prof Hadiarto Mangunnegoro (Indonesia). REVIEW ARTICLE

Effects of ambient particulate matter on peak expiratory flow rates and respiratory symptoms of asthmatics during Asian dust periods in Korea

Abstract: Objective: Dust generating events frequently produce ambient dust particles that are less than 10 µm in diameter, and these have been linked to adverse effects in the general population. However, the evidence linking these particles to adverse effects on the airways of asthmatic individuals is limited. The objective of this study was to investigate the possible adverse effects of Asian dust events on the respiratory functions and symptoms of subjects with bronchial asthma. Methodology: From March to June 2002, individuals were enrolled who had been diagnosed as having asthma by bronchial challenge or by their bronchodilator response. The patients were divided into three groups according to asthma severity: mild, moderate and severe. Patients with other major disease states were excluded. Patients completed twice-daily diaries monitoring PEF, respiratory symptoms, and daily activities. The daily and hourly mean levels of particulate matter <10 µm in diameter (PM10), as well as nitrogen dioxide (NO2), sulphur dioxide (SO2), ozone (O3) and carbon monoxide (CO) were measured at 10 monitoring sites in Incheon, Korea. Results: Dust events occurred 14 times during the study period. On dusty days there were increased levels of PM10, decreased levels of NO2 and SO2, and no change in the CO levels, compared to the levels on control days. An increase in PM10 concentration was associated with increases in PEF variability of >20% (P 20% between the morning and evening values and a relative risk of 1.05 (95% CI, 0.89–1.24) in all subjects. Conclusions: This study provides evidence that Asian dust events are impacting on the respiratory symptoms of subjects with bronchial asthma, and ambient air pollution, particularly elevated PM10, might be one of the aggravating factors.

Inhaled mannitol for the treatment of mucociliary dysfunction in patients with bronchiectasis: Effect on lung function, health status and sputum

Abstract: OBJECTIVE Inhaled mannitol increases mucus clearance in patients with bronchiectasis by an unclear mechanism. The effect of mannitol on lung function, health status and sputum properties was investigated. METHODOLOGY Nine patients with bronchiectasis inhaled 400 mg of mannitol once daily for 12 days. Health status was assessed using the St George's Respiratory Questionnaire (SGRQ). Sputum was analysed for viscosity, elasticity, spinnability, surface tension, contact angle, solids, mucociliary transportability (MCTR) on a frog palate, and cough transportability (CTR) on a simulated cough machine. RESULTS Lung function was unchanged with treatment (baseline FEV1 82.0 +/- 16.2%) apart from an improvement in FEF from 85.4 +/- 13% (baseline) to 90.7 +/- 14.4% (P 0.7), 8.4 +/- 16.0 (P > 0.1) and 19.2 +/- 13.7 (P < 0.005) units, respectively (visit 7). Mannitol reduced the baseline (mean +/- SE) surface tension from 94.5 +/- 1.4 to 84.7 +/- 2.1 mN/m (P < 0.0001), contact angle from 51.1 +/- 2.8 to 33.2 +/- 2.4 degrees (P < 0.0001), spinnability from 11.6 +/- 0.4 to 10.0 +/- 0.2 mm (P < 0.005), and solids from 5.7 +/- 0.4 to 4.3 +/- 0.7% (P < 0.02), acutely (visit 7). Viscosity, elasticity and MCTR did not change significantly, while CTR was increased from 25.8 +/- 1.0 to 34.1 +/- 2.7 mm (P < 0.003). CONCLUSION Mannitol significantly improved the health status over 12 days and this improvement was maintained for 6-10 days after cessation of treatment. In addition, mannitol reduced the tenacity, increased the hydration of mucus acutely and improved cough clearability in patients with bronchiectasis.

Factors related to recurrence of spontaneous pneumothorax

Abstract: Objectives: The purpose of this retrospective study was to identify factors associated with recurrent spontaneous pneumothorax (SP) in southern China, and to compare the therapeutic effectiveness of different procedures. Methods: A total of 182 consecutive patients (89.0% male; mean age, 38.9 years), admitted with their first episode of pneumothorax, were reviewed retrospectively. Follow up was available in 138 patients (75.8%), including 68 treated by chemical pleurodesis and 70 by chest tube drainage alone. The cumulative recurrence rates with different therapeutic procedures and different chemical sclerosing agents were compared, and the factors that influenced the recurrence rate were analysed using Cox's proportional hazard model. Results: The most common pre-existing lung disease responsible for pneumothorax was COPD (69.7%), followed by tuberculosis (16.5%). Recurrence was significantly more common in taller patients, patients with lower weight, and patients with secondary spontaneous pneumothorax. The cumulative recurrence rates in the pleurodesis therapy group after 6 months, 1 and 3 years were 13, 16 and 27%, respectively, whereas in the chest tube drainage group the recurrence rates were 26, 33 and 50%, respectively (P < 0.05). There was no significant difference in the recurrence rate for those receiving tetracycline compared with those who received gentamicin. Conclusions: Spontaneous pneumothorax patients who are taller, weigh less or have secondary spontaneous pneumothorax are more likely to have recurrences. The risk of recurrence is reduced in patients who undergo chemical pleurodesis. Since there was no significant difference between intrapleural tetracycline and gentamicin, gentamicin should be considered as a potential chemical sclerosing agent.

Advances in the diagnosis, evaluation, and management of malignant pleural mesothelioma

Abstract: Malignant mesothelioma is an insidious neoplasm arising from the mesothelial surfaces of the pleural and peritoneal cavities, the pericardium, or the tunica vaginalis. A total of 80% of all cases are pleural in origin. The predominant cause of malignant mesothelioma is inhalational exposure to asbestos, although evidence is increasing to support the hypothesis that simian virus-40 virus plays a role in cocarcinogenesis. Immunohistochemical markers such as calretinin, WT-1, and cytokeratin 5/6 are becoming established diagnostic markers. Preliminary data suggests that a soluble form of mesothelin could serve as a serum marker for established and early cases of mesothelioma. Positron emission tomography with 18-fluorodeoxyglucose in conjunction with computed tomograhy scanning has improved preoperative imaging and staging. Prognostic factors have been identified and verified. Negative indicators include thrombocytosis, high leukocyte counts, poor performance status, and nonepithelial histology. For the first time, there is now evidence that some treatments are increasing the quality and quantity of life for patients with mesothelioma. Chemotherapy, with the new multi-targeted antifolate drug Pemetrexed, combined with cisplatin, has shown superior survival rates in a large phase III trial when compared to cisplatin alone. High-dose intensity-modulated radiotherapy when administered after extrapleural pneumonectomy has resulted in excellent local control. Multimodality treatment programs that combine surgical cytoreduction with novel forms of radiation therapy and more effective chemotherapy combinations may offer significant increases in survival for certain subgroups of mesothelioma patients. Innovative palliative approaches have proved successful in alleviation of the significant symptoms experienced by many mesothelioma patients. Experimental treatments such as immunotherapy and gene therapy present a window of hope for all mesothelioma patients, and in the future, may be combined with 'standard therapy' in multimodality protocols. Patients with adequate performance status should be enrolled into clinical trials where possible. Over the past decade, significant advances have been made on several fronts that have improved the ability to diagnose a stage, define prognosis, and treat malignant pleural mesothelioma.

Outcomes and health-related quality of life following hospitalization for an acute exacerbation of COPD

Abstract: Objective: The purpose of this study was to understand the outcomes for patients admitted to hospital for an acute exacerbation of COPD, and to determine the factors influencing quality of life and health service utilization of patients with COPD. Methodology: Hospital outcomes of 282 patients with moderate and severe COPD, for an acute exacerbation, were retrospectively evaluated. After 24 months of follow up, health-related quality of life (QoL) and health service utilization (emergency room (ER) visit and readmission) in 54 patients admitted previously, were surveyed by questionnaires. Results: Of 282 COPD patients admitted for an acute exacerbation, 28 patients (9.9%) died during hospitalization, 241 patients (85.5%) were discharged home, and only 13 patients (4.6%) needed long-term care facilities. Although over 50% of the patients had survived over 2 years after discharge, their QoL was poor. Patients who frequently went to the ER or were admitted, were those with poor QoL, severe dyspnoea and frequent exacerbation. COPD exacerbation and dyspnoea were the main factors influencing QoL of the patients. Age, comorbidity, QoL, FEV1, frequency of COPD exacerbation, long-term oxygen therapy, and family doctor were the factors determining the likelihood of patients visiting the ER. Frequency of COPD exacerbation, family doctor and living alone were the factors determining which patients were likely to be admitted to hospital. Conclusion: The outcomes and QoL of patients admitted for an acute exacerbation of COPD were poor. The major factors influencing QoL were frequency of COPD exacerbation and severity of dyspnoea. Improvement of social and medical networks (e.g. reducing the number of patients living alone and providing family doctors for patients) may reduce health care service utilization.

Importance of atopic cough, cough variant asthma and sinobronchial syndrome as causes of chronic cough in the Hokuriku area of Japan.

Abstract: Objective: A prospective multicentre study was conducted to elucidate the causes of chronic cough in Japan. Methodology: All consecutive and unselected patients complaining of cough lasting 8 weeks or more, who visited our clinics from 1 June to 31 December 2001, were registered. The causes of chronic cough were diagnosed based on the criteria for definite and probable causes of cough as recommended by the Japanese Cough Research Society. Results: Of the 248 patients enrolled, 72 patients (29.0%) were unavailable for follow up before their diagnostic assessment had been finalized. Among the 176 patients who were adequately assessed, a diagnosis was made in 165 patients (93.7%) either as single cause or as one of two casuses: atopic cough in 48 (29.1%) and 11 patients (6.7%); cough variant asthma in 46 (27.9%) and nine patients (5.5%); cough predominant asthma in 14 (8.5%) and three patients (1.8%); and sinobronchial syndrome (SBS) in 28 (17.7%) and 14 patients (8.5%), respectively. A diagnosis of gastro-oesophageal reflux-associated cough was made in a total of four patients (2.4%). Conclusion: Atopic cough, asthmatic cough consisting of cough variant asthma and cough predominant asthma, and SBS are major causes of chronic cough in Japan.

Lung cancer in Asian women-the environment and genes.

Abstract: The mortality rate of lung cancer in Asian women has increased significantly in the past few decades. Environmental factors include tobacco smoke (active and environmental), other indoor pollutions (cooking oil vapours, coal burning, fungus spores), diet, and infections. Active tobacco smoking is not the major factor. The relative risk of lung cancer among non-smoking women ever exposed to environmental smoke from their husbands was 1.20 from a meta-analysis. Cooking oil vapours associated with high temperature wok cooking and indoor coal burning for heating and cooking in unvented homes, particularly in rural areas, are risk factors for Chinese women. Chronic benign respiratory diseases due to the fungus Microsporum canis probably accounts for the high incidence of lung cancer in northern Thai women at Sarapee. Diets rich in fruits, leafy green vegetables, and vitamin A are protective, while cured meat (Chinese sausage, pressed duck and cured pork), deep-fried cooking, and chili increased the risk. Tuberculosis is associated with lung cancer. Also, a Taiwanese study showed that the odds ratio of papillomavirus (HPV) 16/18 infection in non-smoking female lung cancer patients was 10.1, strongly suggesting a causative role. Genetic factors have also been studied in Chinese women, including human leucocyte antigens, K-ras oncogene activation, p53 mutation, polymorphisms of phase I activating enzymes (cytochrome P450, N-acetyltransferase slow acetylator status), and phase II detoxifying enzymes (glutathione-S-transferases, N-acetyltransferase rapid acetylator status). New molecular screening technology would facilitate identification of molecular targets for future studies. The interaction between environmental and genetic factors should also be further elucidated.

The changing face of healthcare worker perceptions on powered air-purifying respirators during the SARS outbreak.

Abstract: Objectives: Before the advent of severe acute respiratory syndrome (SARS), use of the powered air-purifying respirator (PAPR) in the setting of pulmonary tuberculosis has been controversial. Data regarding health care worker (HCW) perceptions and problems encountered with the use of the PAPRs were lacking. Methodology: A questionnaire-based survey was conducted of HCWs who had used the PAPR in clinical practice during the SARS outbreak, when use of the PAPR was mandatory and widespread. Evaluations of the question of whether HCWs were receptive to the use of the PAPR and their perceptions of common problems that were encountered were made. Perceptions of comfort, ease of use, visual, hearing, breathing and speech impairment, perceived protection against SARS and usage preferences were recorded. Results: Only a minority of respondents found the PAPR uncomfortable, despite some interference with communication. Despite its much higher cost, the majority (84%) preferred to use the PAPR rather than the N-95 respirator when treating suspected SARS patients. However, opinions were equally divided regarding its use when treating patients with pulmonary tuberculosis; with 51% being in favour. Conclusions: With the advent of highly contagious diseases that pose a major occupational hazard to HCWs, the use of the PAPR has become more acceptable in clinical practice.

Rigid and semirigid pleuroscopy: the future is bright.

Abstract: Pleuroscopy provides the pulmonologist with a unique opportunity to visualize the contents of the pleural space, perform biopsy of the parietal pleura under direct visual guidance, allow optimal chest tube placement and perform pleurodesis to prevent recurrent pleural effusion or pneumothorax in selected patients. We discuss the techniques, indications, contraindications and complications of pleuroscopy using rigid and semirigid instruments. In addition, the potential value and expanding role of pleuroscopy with semirigid instrumentation is debated.

A pilot study of aerosolized N‐acetylcysteine for idiopathic pulmonary fibrosis

Abstract: Objective: Idiopathic pulmonary fibrosis poses a significant therapeutic challenge because of its progressive course. Since oxidative stress plays an important role in the pathogenesis of idiopathic pulmonary fibrosis, an open, randomized trial of long-term inhalation therapy with the antioxidant, N-acetylcysteine was conducted. Methodology: A total of 30 patients with idiopathic pulmonary fibrosis were randomly assigned to one of the following inhalation therapies: N-acetylcysteine (352 mg per day) or bromhexine hydrochloride (4 mg per day) as the control. Efficacy was assessed by analysing changes occurring from baseline to 12 months in pulmonary function, the 6-min walking test, high-resolution CT, health-related quality of life, and serum KL-6-values. Results: Four patients (n = 2 in each group) died within 12 months due to progression of idiopathic pulmonary fibrosis. A total of 22 patients (control, n = 12; N-acetylcysteine, n = 10) completed the study. At 12 months there were significant differences between the N-acetylcysteine and control groups in terms of mean changes in lowest SaO2 during the 6-min walking test (−0.3 ± 2.1% vs −6.8 ± 1.8%, P < 0.05), serum KL-6 (−482 ± 220 U/mL vs 176 ± 204 U/mL, P < 0.05), and the ground-glass score on high-resolution CT (−1.3 ± 1.6 vs 6.7 ± 1.5, P < 0.01). No significant differences were observed in pulmonary function, 6-min walking distance or quality of life. Conclusions: These data suggest that although long-term aerosolized N-acetylcysteine administration did not influence pulmonary function or quality of life, it may delay disease progression as evidenced by exercise desaturation, high-resolution CT, and serum KL-6.

Asthma control in adults in Asia-Pacific.

Abstract: Objective The Asthma Insights and Reality in Asia-Pacific (AIRIAP) survey collected detailed information on asthma severity and management in the urban centres of eight areas of the Asia-Pacific region. This study compared asthma morbidity and management practices in these areas. Methodology Following recruitment, face-to-face interviews were completed with 2323 adults with diagnosed asthma, who had current symptoms or were using asthma medication. Comparisons between areas were made for asthma severity, asthma burden and management practices. Results Asthma severity varied significantly between areas (P < 0.01), with Vietnam and mainland China reporting the most cases with severe, persistent symptoms. Severity of asthma was significantly associated with advancing age and a lower level of education in a multivariate analysis (P < 0.001). The total use of acute healthcare for asthma was significantly associated with increased asthma severity. Work absence due to asthma was highest in the Philippines (46.6%) and lowest in South Korea (7.5%). The use of inhaled corticosteroids was associated with age in a non-linear manner. There was significant variation among countries in usage of inhaled corticosteroids, from 1.3% in South Korea to 29.0% in Taiwan (P < 0.00001). A peak flow meter was owned by a total of 7.7% of respondents, and overall, 17.9% of adults had a written action plan for asthma management. Conclusions Within the Asia-Pacific region, asthma in adults differs significantly in disease severity, management and treatment according to area of residence. International recommendations on the management of asthma are generally not being followed.

Pathogenesis of malignant pleural mesothelioma

Abstract: Malignant pleural mesothelioma (MPM) results from neoplastic transformation of mesothelial cells. Past asbestos exposure represents the major risk factor for MPM, as the link between asbestos fibres and MPM has been largely proved by epidemiological and experimental studies. Asbestos fibres induce DNA and chromosome damage linked to oxidative stress following phagocytosis. Recently, simian virus 40 (SV40) has been implicated in the aetiology of MPM. The origin of human infection has been associated with SV40-contaminated polio vaccines, although to date, no epidemiological data supports this hypothesis. SV40 may act as a coactivator of asbestos in mesothelial oncogenesis. The transforming potency of SV40 results from the activity of two viral proteins, large T and small t antigens. SV40 infection stimulates production of growth factors elsewhere implicated in autocrine growth of mesothelioma cells and inactivates RASSF1, a gene silenced in MPM. Roles for ionising radiation, chemicals or genetic factors have also been suggested from the observation of sporadic MPM cases or animal studies. Genetic alterations in the tumour suppressor genes, P16/CDKN2A and neurofibromatosis 2 (NF2), are found both in human MPM and in asbestos-exposed Nf2-deficient mice. MPM is still of great international concern. Despite a ban on asbestos use in Western countries, the incidence of MPM is increasing, due to the long delay between asbestos exposure and diagnosis. Moreover, asbestos is still used in developing countries. The implication of other risk factors, especially SV40, supports a need for further research into MPM.

Predictive equations and the reliability of the impulse oscillatory system in Japanese adult subjects.

Abstract: Background: The impulse oscillation system (IOS) measures respiratory impedance (Zrs) in terms of resistance (Rrs) and reactance (Xrs) at multiples of 5 Hz. These measurements can be used clinically to help diagnose and monitor respiratory disorders, independent of effort. Methodology: The predictive equation for resistance at 5 and 20 Hz and impedance at 5 Hz (R5, R20, X5), for the first time, in 299 Japanese adult subjects was determined. In addition, the within single day variation and between day variation were determined. Results: The predictive equation for R5, R20 and X5 revealed a clear difference with respect to the subject's smoking history (lifelong non-smoker, n = 166, adjusted r = 0.55, 0.46 and 0.57, respectively, vs. smoker, n = 133, adjusted r = 0.47, 0.42 and 0.47, respectively). This difference was less obvious with respect to gender (female, n = 120, adjusted r = 0.42, 0.20 and 0.47, respectively, vs. male, n = 179, adjusted r = 0.46, 0.37 and 0.47, respectively). The predictive equations were dependent on the log of height (H) for both R5 and R20, and on age and log of height for X5. The equations were: R5 (KPa/L/s) = −3.841167 × logH + 8.671580; R20 (KPa/L/s) = −2.546561 × logH + 5.841867; and X5 (KPa/L/s) = −0.000097 × Age + 1.018597 × logH − 2.343672. For these parameters there were no statistically significant differences for within day repeatability or between day variations (P > 0.05), suggesting a high degree of reproducibility for IOS measurements. Conclusion: It was possible to determine a predictive equation and confirm a high degree of reliability of IOS parameters in Japanese adult subjects.

Comparison of existing symptom-based questionnaires for identifying COPD in the general practice setting.

Abstract: Objective: Underdiagnosis of COPD is widespread, at least in part due to underuse of spirometry. Symptom-based questionnaires may be helpful as an adjunct to spirometry. The aim of this study was to determine which types of questions might aid in identifying COPD. Methodology: Questionnaires were identified by literature review and input from a multinational advisory board of primary care providers. Questions were placed into groups and evaluated with respect to their ability to perform in two scenarios: (i) to identify persons with COPD from a general population (Case-finding scenario); and (ii) to distinguish persons with COPD from those with asthma (Differential Diagnosis scenario). Questions were retrospectively validated using the Third National Health and Nutrition Examination Survey data. Potential predictive ability was examined in bivariate and multivariate frameworks. Results: Four published question sets and six additional documents were included. There was agreement in the use of smoking and symptom-based questions, but important differences in the use of demographic, personal history and other information. Most question types had significant bivariate relationships with airway obstruction. In multivariate analysis, age, BMI, smoking status and pack-years, symptoms (cough, phlegm, dyspnoea, wheeze), and prior diagnosis consistent with asthma or COPD all showed significant ability to discriminate between persons with and without obstruction in a general population. Conclusion: Simple self-administered questionnaires can be used to identify persons for whom spirometric testing may be especially appropriate. Development of such questionnaires will require additional study, including prospective validation of items in an appropriate clinical setting and policy recommendations on the use of these tools.

Predictors of success in smoking cessation among hospitalized patients

Abstract: Objective: To determine the predictors of continued smoking abstinence in patients receiving smoking cessation intervention during and following hospital admission. Methodology: A prospective cohort study was conducted in a university-affiliated hospital. A total of 248 smokers admitted with primary cardiac and respiratory conditions received verbal advice (lasting about 1 h) and standard booklets on smoking cessation from a dedicated nurse counsellor. After discharge, participants received follow-up telephone counselling calls every 2 weeks from the same smoking counsellor. The main outcome measure was continued abstinence at 2 months after hospital discharge, as determined by self-reporting and carbon monoxide breath testing. The following groups of covariates were analysed to determine the possible factors associated with smoking abstinence: demographics, smoking history, readiness to quit, and medical history. Results: At 2 months post-discharge, 108 (43.5%) patients remained abstinent. Low nicotine dependence score (odds ratio, 2.30; 95% CI, 1.25–4.26; P = 0.008), decision to quit by sudden cessation as compared to reduction of smoking (odds ratio, 7.19; 95% CI, 1.56–33.06; P = 0.011), and initial hospitalization for their medical condition (odds ratio, 6.37; 95% CI, 1.33–30.44; P = 0.020) were the main independent predictors for positive outcome. Conclusion: Among this cohort of hospitalized patients receiving smoking cessation intervention, low dependence on tobacco, motivation to quit by sudden cessation, and initial hospitalization were the main independent predictors of smoking abstinence after discharge from hospital.

Clinicopathological differences between acute and chronic eosinophilic pneumonia.

Abstract: Objective: Considerable confusion exists regarding the proper classification of idiopathic eosinophilic pneumonia (IEP). Furthermore, there are no reports describing the clinicopathological differences between the various forms of eosinophilic pneumonias. Methodology: The histological findings in acute eosinophilic pneumonia (AEP) and chronic eosinophilic pneumonia (CEP) were examined and the clinical and radiological features were contrasted with them. Results: Radiologically, ground glass opacity and interlobular septal thickening were characteristic of the AEP cases, while air space consolidation was seen in all CEP cases. Histologically, interstitial oedema and fibrin deposition were prominent in the AEP cases. Type II cells were detached from the alveolar walls, although the basal lamina was predominantly intact. In CEP, in addition to cellular infiltration, there was prominent intraluminal fibrosis. Disruption of the basal lamina was observed and nests of intraluminal fibrosis were directly adjacent and connected to the alveolar walls. Conclusions: An essential histological difference between AEP and CEP is the severity of basal lamina damage and the amount of subsequent intraluminal fibrosis. In AEP particularly, these findings explain the radiographical findings, as well as the rapid and complete improvement noted in such cases.

The effect of Ramadan fasting on spirometry in healthy subjects.

Abstract: Objectives: Lung function tests are an important investigative tool in diagnosing respiratory diseases, judging their severity and assessing prognosis. The primary aim of the present study was to assess whether Ramadan fasting affected normal lung function values. Methodology: Forty-six non-smoking healthy males, with a mean age of 24.2 years (SD 6.4 years) were investigated. Spirometry was performed according to the recommendations of the American Thoracic Society. Days between the 15th and 25th of three Islamic months (pre-Ramadan, Ramadan and post-Ramadan) were selected for spirometry. On all three occasions, FVC, FEV1, FEV1/FVC%, maximum voluntary ventilation (MVVindirect), PEF, FEF25−75% and body mass were measured. Pre- and post-Ramadan readings were compared with the readings during Ramadan fasting. The results were analysed by repeated measures analysis of variance. Results: No significant change was seen in lung function during Ramadan as compared to the pre-Ramadan period. FVC was decreased significantly in the post-Ramadan period compared to Ramadan and this period was associated with a significant increase in body mass. Conclusion: Relative to pre-Ramadan baseline values, there was no change in spirometry during Ramadan fasting in these subjects.

Augmentation of allergic inflammation in the airways of cyclooxygenase-2-deficient mice.

Abstract: Objective: Airway cyclooxygenase-2 (COX-2) is induced by cytokine-mediated inflammation such as occurs in asthma. However, the role of COX-2 in the pathophysiology of asthma is not fully understood. Methods: Allergic inflammation, airway responsiveness to methacholine and mucous cell metaplasia after ovalbumin sensitization in the airways of COX-2 deficient (–/–) mice, COX-2 (+/+) mice and C57BL/6J mice treated with a selective COX-2 inhibitor, nimesulide were assessed. Histology, cell analysis, measurements of arachidonic acid metabolites and Th2 cytokine levels in bronchoalveolar lavage fluid (BALF), and measurement of serum IgE were performed. Results: Eosinophil infiltration into the airway wall, and the number of eosinophils in BALF were greater in sensitized COX-2 (–/–) mice than in sensitized COX-2 (+/+) mice. The levels of cysteinyl leukotrienes (LTC4/D4/E4), prostaglandin E2 (PGE2) and interleukin (IL)-13 as well as airway responsiveness did not differ in COX-2 (–/–) mice and COX-2 (+/+) mice. However, sensitized COX-2 (–/–) mice had higher LTC4/D4/E4 and lower PGE2 concentrations compared with non-sensitized COX-2 (–/–) mice. The number of PAS/alcian blue-positive airway epithelial cells and serum IgE were elevated in COX-2 (–/–) mice. Nimesulide-treated mice showed augmented eosinophilic inflammation, LTC4/D4/E4 concentrations and mucous cell metaplasia. Conclusion: These data indicate that COX-2 deficiency augments allergic inflammation and mucous cell metaplasia.

Contribution of aspirin-intolerant asthma to near fatal asthma based on a questionnaire survey in Niigata Prefecture, Japan.

Abstract: Objective: Prevention of deaths due to asthma is one of the most important issues in asthma management. However, there are few epidemiological studies of asthma deaths in Japan. Methodology: Over an 8-week period in Niigata Prefecture, Japan, a questionnaire on asthma control and emergency episodes was administered to adult asthmatic patients. A questionnaire was also given to the patients’ physicians to obtain further clinical information. Patients who became unconscious during episodes of asthma, or who required intubation and ventilation, were allocated to a near-fatal asthma group (NFA). Patients who did not fulfill these criteria were allocated to the non-NFA group. The NFA group was divided into two subgroups, based on the date of their last NFA episode (old NFA ≥ 5 years and recent NFA < 4 years). Results: Characteristic features of the NFA group included severe disease (23.1%vs 7.6%) with more aggressive patient management, including inhaled corticosteroid use (84.3%vs 72.0%). Multiple regression analysis confirmed that aspirin-intolerant asthma (AIA) was strongly associated with NFA. There was no difference in the incidence of AIA between the recent and old NFA patients. This suggests the incidence of AIA in NFA did not improve over time. Conclusions: A history of AIA may be a useful indicator of potential NFA and allow preventative methods to be introduced. It is therefore important to obtain a history of AIA and to be aware of the risk of NSAID administration to these patients.

Prolonged survival after talc poudrage for malignant pleural mesothelioma: case series.

Abstract: Objective: Malignant pleural mesothelioma is a fatal disease with a mean life expectancy of 6–12 months. Since 1982, we have performed thoracoscopic talc poudrage (TTP) as a primary therapy in mesothelioma patients presenting with pleural effusion. As the survival data for our patients surpassed that of many published series, the patient data was analyzed to determine whether talc poudrage can be considered as a contemporary palliative option. Methodology: We reviewed all 26 patients with a final diagnosis of malignant pleural mesothelioma from our prospective database of 228 consecutive patients who received thoracoscopy from the same physician for recurrent symptomatic pleural effusion. Patients were followed up until their death. Results: Mean survival after TTP was 23.8 ± 16.3 months (median 19.4, range 2.9–68). Pleurodesis palliated dyspnoea in all patients. No perioperative deaths and one postoperative complication (pneumonia) occurred. Mean hospital stay was 3.9 ± 2.7 days. Conclusion: TTP remains a safe, low-morbidity, inexpensive primary palliative treatment option for malignant pleural mesothelioma and a valid control arm option for therapeutic trials. TTP is ideal for patients who wish to avoid thoracotomy, long hospital stays and morbidity from multimodality therapy. Prospective randomized studies are needed to compare quality of life and survival after talc poudrage and other therapies.

Prevalence of asthma, eczema and allergic rhinitis: two surveys, 6 years apart, in Kota Bharu, Malaysia.

Abstract: Objective: This study was undertaken to determine the prevalence of asthma, eczema, and allergic rhinitis in school children in Kota Bharu, Malaysia, and in so doing to determine the differences in symptom prevalence rates of asthma, and atopic diseases in Kota Bharu school children between 1995 and 2001. Methodology: In two studies (1995 and 2001), year one primary school (PS) pupils (6–7 years old) and secondary school (SS) year two pupils (13–14 years old) were randomly selected from the district of Kota Bharu, Kelantan, Malaysia. In 1995, 3939 PS children and 3116 SS children participated, and in 2001 3157 PS children and 3004 SS children participated. The Phase I International Study of Asthma and Allergies in Childhood prevalence written questionnaire and video questionnaire (only shown to SS children) were used in both studies. Results: The written questionnaire showed no significant changes in the prevalence (1995, 2001) of ever wheeze (8.3%, 6.9%P = 0.06), current wheeze (5.4%, 4.3%P = 0.08), exercise-induced wheeze (EIW; 3.9%, 3.7%P = 0.63), and rhinoconjunctivitis (4.6%, 5%P = 0.42) among PS children. The prevalence of flexural itchy rash increased from 14% to 17.6% (P = 0.004) and night cough decreased from 20.4% to 17.5% (P = 0.005). There were also no significant changes in these symptoms among SS children (1995, 2001): ever wheeze (10.7%, 12%P = 0.37), current wheeze (6.8%, 5.7%P = 0.20), EIW (9.9%, 11.6%P = 0.28), night cough (21.6%, 24%P = 0.39), rhinoconjunctivitis (11%, 15%P = 0.11), and flexural itchy rash (12%, 13%P = 0.11). The video questionnaire showed no significant changes in the prevalence of symptoms in the previous 12 months (1995 vs 2001) for wheeze at rest (3.8%, 2.8%P = 0.12), EIW (6.9%, 8.8%P = 0.32), waking with wheeze (1.7%, 1.7%P = 1.0), and severe wheeze (2.1%, 3%P = 0.12). Night cough in the previous 12 months increased significantly from 5.1% to 8.3% (P = 0.007). Conclusion: Although asthma and atopic disorders are common in this country, the results revealed no major changes in the prevalence rates of these diseases over a period of 6 years.

Effect of smoking on FEV1 decline in a cross-sectional and longitudinal study of a large cohort of Japanese males

Abstract: Objective: The effects of cigarette smoking and smoking cessation on age-related pulmonary function decline was assessed in both cross-sectional and longitudinal studies. Methodology: In the cross-sectional study, pulmonary function data from 11 875 healthy asymptomatic males, aged between 35 and 74, were analysed and correlated with their smoking history and age. In the longitudinal study, changes in pulmonary function were monitored over a 5-year period in 1888 healthy males. Results: The cross-sectional study showed that the difference in FEV1 between male never smokers and current smokers was small at a younger age but increased with age. A beneficial effect on FEV1 decline was observed in those who ceased smoking, even within the previous 12 months. Longitudinally, current smokers showed a more rapid decline in FEV1 over the 5-year period than non-smokers. Those who ceased smoking had lower rates of decline in FEV1 than those who continued to smoke. Conclusion: These results indicate that cigarette smoking is associated with a reduction in pulmonary function, and that smoking cessation has a beneficial effect on FEV1 decline. Provision of a smoking cessation program for all smokers, especially those showing a rapid decline of FEV1, should be considered as an important strategy to prevent progression of COPD.

Antioxidant enzyme activities in healthy Chinese adults: influence of age, gender and smoking.

Abstract: Objective: Specific antioxidant enzymes play a vital role in regulating and maintaining oxidant species. The aim of this study was to determine these antioxidant enzyme activities (i.e. catalase (CAT), superoxide dismutase (SOD) and glutathione peroxidase (GPx)) in erythrocytes from a group of healthy Chinese subjects and to study the influence of age, gender and smoking habits on the enzyme activities. Methodology: Chinese healthy subjects (n = 276) were grouped according to their age range, gender differences and smoking habits. Antioxidant enzyme activities were measured spectrophotometrically using standard kinetic methods. Results: There was a significant decrease in erythrocyte GPx activity in ever-smokers compared with non-smokers (47.10 ± 1.33 mU/g haemoglobin (Hb) vs. 51.41 ± 1.64 mU/g Hb, P 60 years old, erythrocyte CAT and GPx activities were significantly lower in ever-smokers than in non-smokers (29.70 ± 3.07 mU/g Hb vs. 41.63 ± 4.92 mU/g Hb (P < 0.05), and 47.55 ± 2.00 mU/g Hb vs. 55.30 ± 3.60 mU/g Hb (P < 0.05), respectively). It was also found that females had higher erythrocyte GPx activity than males but this difference did not reach significance in non-smokers. Conclusion: From the results of this study, it is concluded that oxidative stress seems to be present in elderly ever-smokers among the Chinese population.

Prevalence and clinical features of cough variant asthma in a general internal medicine outpatient clinic in Japan

Abstract: Objective: The aims of the present study were to examine the prevalence and clinical features of cough variant asthma (CVA) among patients with chronic and persistent cough at an outpatient clinic in Japan, and the efficacy of treatment with an inhaled corticosteroid. Methodology: This prospective study was conducted at a general internal medicine outpatient clinic in Japan over a 12-month period. CVA was diagnosed as chronic cough without wheezing or any apparent cause, that had persisted for more than 8 weeks, with a normal CXR and spirometry but with bronchial hyperresponsiveness to methacholine, and relief of cough after bronchodilator treatment. We also examined the effects of inhaled beclomethasone propionate on symptoms and differences in PEF between early morning and evening. Results: Of 55 patients suffering from chronic cough, 23 satisfied the criteria for CVA. Their cough occurred more frequently at night and early in the morning. Early morning PEF was significantly lower than evening PEF with a mean variability of 11.5 ± 4.1%. Treatment with beclomethasone propionate improved coughing and significantly increased early morning PEF, reducing variability to less than 10%. Conclusions: These findings suggest that CVA is most common among patients with chronic cough not due to any apparent cause. The efficacy of inhaled corticosteroid suggests that early intervention is effective in the treatment of CVA.

The impact of dyspnoea and leg fatigue during exercise on health-related quality of life in patients with COPD.

Abstract: Objective: COPD patients frequently complain of symptoms such as dyspnoea and leg fatigue during exercise. However, the impact of these symptoms on the health-related quality of life (HRQoL) is not known. This study tested whether dyspnoea and leg fatigue during exercise affects the HRQoL of patients with COPD. Methods: In a cross-sectional study, 90 patients with stable COPD (mean age, 76.0 ± 0.7 years; FEV1, 1.11 ± 0.04 L) completed the St. George's Respiratory Questionnaire (SGRQ), pulmonary function testing, arterial blood gas analysis, and a 6-min walking distance test (6MWD). Dyspnoea and leg fatigue during exercise were quantitated into 12 grades using the Borg scale (0–10). Correlations between the SGRQ and various variables were determined. In a longitudinal study, 22 patients with COPD (mean age, 71.5 ± 1.1 years; FEV1, 1.31 ± 0.08 L) completed a pulmonary rehabilitation program, for which correlations between changes in the SGRQ as well as changes in both dyspnoea and leg fatigue, during the 6MWD before and 3 months after pulmonary rehabilitation, were examined. Results: For the cross-sectional study, the total SGRQ score correlated significantly with the walking distance, dyspnoea and leg fatigue during the 6MWD and FEV1, respectively. Stepwise multiple regression analysis showed that dyspnoea and leg fatigue during the 6MWD were independent variables for HRQoL measured by the SGRQ. For the longitudinal study, changes in the SGRQ correlated significantly with changes in dyspnoea and leg fatigue, before and 3 months after, pulmonary rehabilitation. Conclusions: Symptoms, such as the degree of dyspnoea and leg fatigue during exercise, are significant variables which influence the HRQoL of patients with COPD. In addition, the improvement in HRQoL following pulmonary rehabilitation may be due to improvements in dyspnoea and leg fatigue in patients with COPD.

Endobronchial metastases: a clinicopathological analysis.

Abstract: Objective: It is important to distinguish endobronchial metastases (EBM) from both primary lung cancers and benign lesions, as treatment will differ. The clinicopathological characteristics of EBM cases were documented to see whether any distinguishing features exist. Methodology: Histological cases diagnosed as EBM in the pathology laboratory of a tertiary hospital were re-evaluated. Symptoms, primary tumour sites, recurrence interval, radiological and bronchoscopic features, and histopathological properties were assessed. Results: There were 18 cases (eight female, 10 male) with EBM. All were diagnosed by bronchoscopic bronchial biopsy. The primary tumour sites were: colorectal (4), breast (3), renal (3), lymphoma (3), rhabdomyosarcoma (2), bladder (1), thyroid (1) and malignant melanoma (1). The mean time from the diagnosis of the primary tumour to their presentation was 3.89 ± 1.09 (range, 0–19) years. In five patients, EBM was diagnosed synchronously with their extra pulmonary primary tumour. Two had other metastatic sites. Haemoptysis and cough were the more common symptoms. Interestingly, three patients were asymptomatic. There was no predilection for a particular airway segment to be involved but a predilection for the upper lobe existed. Endoscopic appearance was polypoid in 10 cases and mucosal infiltration in the remainder. Histopathological examination revealed epithelial tissue at the surface of the tumour in nine cases and four of these were metaplastic. In all but one there was inflammation, mainly lymphocytic. Necrosis was present in 10 cases and bleeding was seen in four. There were no statistically significant differences between the level of lymphocytic inflammation and other clinicopathological parameters. Conclusion: EBM is a rare condition that can be synchronous or occur late. Surprisingly, it can be asymptomatic. It is usually found in the upper lobes. Lymphocytic inflammation is a common histopathological finding. There is need for further studies to clarify the clinical importance of EBM.

The efficacy of incentive spirometry in patients with COPD

Abstract: Objective: Although incentive spirometry (IS) is frequently used to prevent postoperative pulmonary complications, its efficacy in patients with COPD has not been documented. The aim of this study was to evaluate the effects of IS on pulmonary function tests, arterial blood gases, dyspnoea and health-related quality of life in patients hospitalized for COPD. Methodology: A total of 27 consecutive patients (mean age, 68.4 ± 7.9 years; 26 males) admitted for COPD exacerbations were recruited for the study. In total, 15 (IS treatment group) used IS for 2 months, together with medical treatment. The remaining 12 (medical treatment group) were given only medical treatment. Pulmonary function and blood gases were measured. Assessment of dyspnoea by visual analogue scale (VAS) and quality of life using the St. George's Respiratory Questionnaire (SGRQ) were performed at admission and after 2 months of treatment. Results: The activity, impact and total scores for the SGRQ improved (all P ≤ 0.0001), PaCO2 values decreased (P = 0.02), PaO2 and PAO2 values increased (P = 0.02 and P = 0.01, respectively) in the IS treatment group. However, there were no significant differences between the measurements made pretreatment and after 2 months of medical therapy in the medical treatment group, with regards to pulmonary function, blood gases, SGRQ scores and VAS. Conclusion: The use of IS appears to improve arterial blood gases and health-related quality of life in patients with COPD exacerbations, although it does not alter pulmonary function parameters.

Tumor necrosis factor-alpha gene promoter polymorphism is not associated with smoking-related COPD in Thailand.

Abstract: Objective: Susceptibility to COPD is, in part, genetically determined. Tumour necrosis factor (TNF)-α gene promoter polymorphisms have been investigated in different populations with inconsistent results. This study aimed to determine the genetic predisposition in Thai smoking-related COPD patients. Methodology: The polymorphism at position −308 of the TNF-α gene promoter was examined in 57 patients with smoking-related COPD, 67 smoker control subjects, and 116 control anonymous blood donors. Genomic DNA from peripheral blood lymphocytes was used for genotypic analysis by polymerase chain reaction with sequence specific primers. Results: TNF-α-308*2 allele frequency was not significantly different between the population control subjects and the smoking-related COPD patients (4.7% vs. 7.9%, P= 0.14). This allele frequency was also not significantly different between smokers with and without COPD (7.9% vs. 7.5%, P= 0.46). Conclusions: Although it has been speculated that TNF-α might have a causal relationship with COPD, a role for the TNF-α gene promoter polymorphism in disease development in Thailand was not demonstrated.

Nasal wash as an alternative to bronchoalveolar lavage in detecting early pulmonary inflammation in children with cystic fibrosis.

Abstract: Objective: The aim of this study was to determine whether nasal inflammation reflects pulmonary inflammation in young children with cystic fibrosis (CF), as assessed by inflammatory markers in nasal wash (NW) and bronchoalveolar lavage (BAL), respectively. Methods: CF patients younger than 6 years of age who were to undergo bronchoscopy for routine BAL from May 2000 to October 2001 were recruited for this study. NW was collected immediately after the patient was sedated for bronchoscopy. Total cell counts (TCC), differential cell counts and interleukin (IL)-8 levels (enzyme-linked immunosorbent assay) were assessed in NW and BAL. Results: In total, 19 children with CF (mean age, 1.9 years; SD, 1.7 years) were included in the study. There was a significant relationship between IL-8 and the percentages of neutrophils in NW (r 2 = 0.76; P < 0.001) and in BAL fluid (r2 = 0.62; P = 0.006). Similarly, IL-8 concentrations in the NW correlated with those in the BAL (r2 = 0.48; P = 0.036) and neutrophil percentages in NW correlated significantly with those in BAL (r2 = 0.7; P = 0.004). Conclusion: When measured under 'ideal' conditions, nasal IL-8 reflects lower airway levels and may reflect the inflammatory stimulus that results in neutrophilic inflammation. These data encourage further assessment of nasal wash under clinically appropriate conditions to determine its utility for assessing inflammation in young children with CF.