B. Jayakrishnan

Asthma control: importance of compliance and inhaler technique assessments

Abstract Objectives: The available assessment tools to determine asthma control do not include components assessing factors that may directly affect control. Our aim was to evaluate the relationship between patient compliance, inhaler technique and the level of asthma control. Methods: Scores from the Asthma Control Test, individual inhaler device checklists and a novel questionnaire on the patient’s medication regimen were used to measure control, inhaler technique and compliance, respectively, in patients with asthma attending Sultan Qaboos University Hospital, Muscat, Oman during a 3-month period. Results: All of the 218 patients were receiving inhaled steroids, either in combination with long-acting beta agonists (86.2%) or alone. Asthma control was good in 92 (42.2%) patients; with 38 males (50%) and 54 females (38%), respectively (p = 0.059). Compliance and inhaler technique were poor in 40.8% (89) and 18.3% (40) of the patients. 60% (36) of the patients with good and 59.4% (41) with partial compliance had good control while 83.1% (74) with poor compliance had poor control (p < 0.001). Of the 92 patients with good control, 86 (93.5%) exhibited good inhaler techniques. In contrast, 85% (34) of the patients with poor inhaler techniques demonstrated poor control (odds ratio [OR] = 5.3; 95% confidence interval [CI]: 2.05–14.8; p < 0.001). A total of 93.3% (56) with good and 89.9% (62) with partial compliance demonstrated good inhaler techniques (p < 0.001). In patients with good control, 35 (38%) exhibited both good inhaler techniques and compliance and 38 (41.3%) had a good technique and partial compliance. Conclusion: Patients with good inhaler techniques and compliance have better control of their asthma. Asthma control will remain suboptimal unless the reasons for this lack of control are identified, assessed and eliminated. We recommend that inhaler technique assessment and measurements of patient compliance with their prescribed treatments should be considered for inclusion in the current assessment tools.

Varicella Zoster Virus Pneumonitis and Brainstem Encephalitis Without Skin Rash in an Immunocompetent Adult

Varicella zoster virus (VZV) pneumonitis and brainstem encephalitis developed in an immunocompetent adult without rash. Chest computed tomography exhibited nodularity; lung biopsy revealed multinucleated giant cells, Cowdry A inclusions, VZV antigen, and DNA. Varicella zoster virus central nervous system disease was verified by cerebrospinal fluid (CSF) anti-VZV IgG antibody with reduced serum/CSF ratios.

Severe Pulmonary Involvement in Leptospirosis : Alternate antibiotics and systemic steroids

Pulmonary complications in leptospirosis, though common, are often unrecognized in a non-endemic area. We report here a patient with leptospirosis and severe pulmonary involvement who was treated with meropenem (1 g every 8 hours), moxifloxacin (400 mg once daily), and high doses of corticosteroids. Systemic steroids were continued for 3 months because of persistent pulmonary lesions.

Asthma inhalers and colour coding: universal dots

The importance of colour-coded asthma treatment in patient education is well accepted. Traditionally, reliever medication inhalers are blue in colour and preventer inhalers brown.1 This custom is not always followed and the inconsistencies in the colour of inhalers create a lot of confusion. Marketing of the same medication in different colour inhalers and introduction of new drugs and combinations contributed to this predicament. The confusion created by the introduction of generic salbutamol in UK in orange-coloured inhalers has been previously discussed.2 Salbutamol in some countries comes in white inhalers with a blue cap. The colour coding of caps is never reliable as patients can easily change these …

Hughes-stovin syndrome and massive hemoptysis: a management challenge.

Hughes-Stovin syndrome is a very rare clinical entity characterized by pulmonary artery aneurysms and deep vein thrombosis (DVT). Here we report the case of a 53-year-old man, admitted to Sultan Qaboos University Hospital, Muscat, Oman, with bilateral pulmonary artery aneurysms and lower-limb DVT who developed massive hemoptysis. He was managed successfully with high-dose steroids in combination with cyclophosphamide.

Chronic renal failure presenting for the first time as pulmonary mucormycosis with a fatal outcome.

Pulmonary mucormycosis is an uncommon, but important, opportunistic fungal pneumonia which is often diagnosed late. Renal failure as the predominant presenting feature is not common in mucormycosis. Moreover, sudden, massive hemoptysis is not a usual complication. In this report we describe fatal pulmonary mucormycosis in a young patient with a previously undiagnosed chronic renal failure.

Peripheral Rim Enhancement in Tuberculous Mediastinal Lymph Nodes

A 50-year-old Arab woman presented with a 3-month history of fever, weight loss, and tiredness. She noticed mild shortness of breath on exertion a month before presentation. She looked fairly healthy, a few cervical lymph nodes were palpable, and the chest examination showed features of a right-sided pleural effusion. A chest radiograph showed a right pleural effusion and mediastinal widening. Computed tomography (CT) confirmed massive mediastinal lymphadenopathy ( Figures 1 and 2 ). The largest lymph node was seen in the right para tracheal area measuring 5 × 3.5 cm. Bilateral pleural effusions were also seen. As seen in the figures, all the lymph nodes showed characteristic central low attenuation with a peripheral rim of enhancement (arrows). A cervical lymph node biopsy showed caseating necrosis and a few acid-fast bacilli, confirming the diagnosis of tuberculosis. HIV serology was negative. CT accurately defines the extent and placement of the lymph nodes. The low attenuation necrotic lymph nodes with rim enhancement after contrast infusion strongly suggest a diagnosis of mycobacterial infection. 1 A similar appearance may be seen in patients with fungal infection, especially Cryptococosis or Histoplasmosis . This appearance is usually not observed in other causes of mediastinal lyphadenopathy such as metastatic carcinoma, lymphoma, sarcoidosis, or leukemia. Low attenuation areas within the nodes represent areas of caseation necrosis and may be a reliable indicator of disease activity. 2,3