Basim A. Dubaybo

Impact of active and passive smoking as risk factors for asthma and COPD in women presenting to primary care in Syria: first report by the WHO-GARD survey group

Background The burden of chronic respiratory disease (CRD) is alarming. International studies suggest that women with CRD are undersurveyed and underdiagnosed by physicians worldwide. It is unclear what the prevalence of CRD is in the general population of Syria, particularly among women, since there has never been a survey on CRD in this nation. The purpose of this study was to investigate the impact of different patterns of smoking on CRD in women. Materials and methods We extracted data on smoking patterns and outcome in women from the Global Alliance Against Chronic Respiratory Diseases survey. Using spirometric measurements before and after the use of inhaled bronchodilators, we tracked the frequency of CRD in females active and passive narghile or cigarette smokers presenting to primary care. We administered the questionnaire to 788 randomly selected females seen during 1 week in the fiscal year 2009–2010 in 22 primary care centers in six different regions of Syria. Inclusion criteria were age >6 years, presenting for any medical complaint. In this cross-sectional study, three groups of female subjects were evaluated: active smokers of cigarettes, active smokers of narghiles, and passive smokers of either cigarettes or narghiles. These three groups were compared to a control group of female subjects not exposed to active or passive smoking. Results Exposure to active cigarette smoke but not narghile smoke was associated with doctor-diagnosed chronic obstructive pulmonary disease (COPD). However, neither cigarette nor narghile active smoking was associated with increased incidence of spirometrically diagnosed COPD. Paradoxically, exposure to passive smoking of either cigarettes or narghiles resulted in association with airway obstruction, defined as forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) < 70% according to the Global initiative for chronic Obstructive Lung Disease criteria; association with FEV1 < 80% predicted, evidencing moderate to severe GOLD spirometric grade, and doctor-diagnosed COPD. Physicians tend to underdiagnose COPD in women who present to primary care clinics. Whereas around 15% of enrolled women had evidence of COPD with FEV1/FVC < 70% after bronchodilators, only 4.8% were physician-diagnosed. Asthma did not appear to be a significant spirometric finding in these female subjects, although around 11% had physician-diagnosed asthma. One limitation is FEV1/FVC < 70% could have also resulted from uncontrolled asthma. The same limitation has been reported by the Proyecto Latinoamericano de Investigacion en Obstruccion Pulmonar (PLATINO) study. Conclusion Contrary to popular belief in developing countries, women exposed to tobacco smoke, whether active or passive, and whether by cigarettes or narghiles, like men are at increased risk for the development of COPD, although cultural habits and taboos may decrease the risk of active smoking in some women. Recommendations These findings will be considered for country and region strategy for noncommunicable diseases, to overcome underdiagnosis of CRD in women, fight widespread female cigarette and narghile smoking, and promote behavioral research in this field.

Plasmacytoma and upper airway obstruction

Extramedullary plasmacytomas are hematologic malignancies that occur primarily in the head and neck region. They usually involve the submucosal lymphoid tissue of the nasopharynx or paranasal sinuses and present as soft tissue masses, but have not been previously reported to cause airway obstruction. In general, detection of plasmacytoma antedates the eventual development of the systemic hematologic malignancy, multiple myeloma, by months or years. We describe a unique case of acute upper respiratory tract obstruction secondary to compression by an extramedullary plasmacytoma occurring in the neck of a patient with history of long-standing multiple myeloma. Upper airway obstruction may be a manifestation of untreated plasmacytoma. It is imperative for otolaryngologists and head and neck surgeons to be familiar with this entity because total excision, as well as radiation therapy, for plasmacytomas can be curative in patients without underlying overt plasma cell dyscrasias.

Compensatory Growth in Fibrotic Lung Injury

We induced severe left-sided lung fibrosis by the unilateral endobronchial instillation of paraquat (1.0 mg/kg) into the left lungs of adult Fischer 344 male rats. Growth of the contralateral lung as well as its proliferative activity were measured 6 or 14 days later. Whereas the left lung underwent severe fibrosis and shrinkage with more than 85% reduction in lung volume, the right lung more than doubled in size. In addition, there was a significant increase in total protein content, DNA content, and DNA synthesis. We conclude that unilateral lung injury resulting in ipsilateral fibrosis and loss of parenchyma is associated with compensatory growth of the contralateral lung.

Managing Bronchial Asthma in Underprivileged Communities

The definition of a primary care facility is the site where the first patient contact occurs. In developing countries, primary healthcare (PHC) facilities are officially healthcare centers, hosting World Health Organization (WHO) programs for tuberculosis and chronic respiratory diseases. In addition, there are many other providers of PHC services, which include emergency departments, general outpatient clinics in public hospitals. Asthma patients may present for treatment in any of these primary care facilities. An internation‐ al study achieved by the Union showed that 51% of asthma patients in Syria are treated in emergency departments only, many developing countries like Sudan, Algeria, and some African countries had the same use of ER. There are questions about the quality of care provided in these clinics with regard to their adherence to Global Initiatives for Asthma (GINA) guidelines. Evidence suggests that there may be over prescribing of oral corticosteroids and antibiotics and under-prescription of inhaled corticosteroids, so there is a need to improve practice bringing it more into alignment to international guide‐ lines. It may be considered by many that it is not possible to follow guidelines in developing countries and those that have economic and political pressures. However, a pilot program to test the feasibility of a providing systematic follow-up of uncontrolled asthma patients in a general free of charge hospital in Syria showed that it is possible to achieve asthma control following to GINA guidelines even in very deprived community. The same was mentioned by the Union in an international survey for other developing African and Mediterranean countries. WHO launched programs for non-communicable disease including chronic respiratory disease: Practical Approach to lung Health (PAL) and Package of essential no communicable (PEN) disease interventions for primary health care in low-resource settings. The IPCRG also worked on how to improve implementa‐ tion of guidelines. We will provide the results and following evidence-based recommen‐ dations from our field surveys in developing countries, as well comment on international programs. Although much progress has been realized in the diagnosis and manage‐ ment of asthma in developed nations, progress in one variant of asthma, inner city asthma, has been slow. Inner city asthma is that variant of the disease which afflicts residents of urban environments with low socioeconomic conditions, poor housing, and rampant