John Abisheganaden

The use of text messaging to improve asthma control: a pilot study using the mobile phone short messaging service (SMS):

We have evaluated the feasibility of using the mobile phone short message service (SMS) for symptom monitoring in patients with asthma. All consecutive patients admitted to hospital for asthma during an 11-month period were considered for enrolment (n = 497). Those meeting the inclusion criteria were randomized into a control (n = 60) and intervention group (n = 60). Patients in the intervention group received SMS messages according to a structured workflow, while patients in the control group had no SMS support. In the intervention group, the mean response rate to the messages was 82%. There was an improvement in the Asthma Control Test (ACT) scores in 36 subjects in the intervention group compared to 28 subjects in the control group. There were reductions in the number of nebulizations in 54 subjects in the control group compared to 50 subjects in the intervention group, and reductions in emergency department visits in 57 subjects in the control group compared to 51 subjects in the intervention group. However, none of these differences were significant. There was no reduction in admission rates in either group (P = 0.5). The service was accepted by most patients, but its long-term effectiveness on the management of asthma remains to be determined.

Economic burden of chronic obstructive pulmonary disease.

Background and objective:  The aim of this study was to estimate the direct medical costs of COPD in two public health clusters in Singapore from 2005 to 2009.

Respiratory monitoring using an air-mattress system

This paper describes a non-invasive respiratory monitoring system using an air mattress. The air-mattress system features multiple air compartments to monitor movements of the thorax and the abdomen separately. To evaluate the performance of the air-mattress system, four subjects were selected for the study and their separate ribcage and abdominal movements were monitored simultaneously by respiratory inductive phlethysmography belts and the air-mattress system. The sensitivity and accuracy indices of the air-mattress system for the detection of hypopnoeas scored remarkably well (above 90%). In addition, it was noted that the mean error in the measurement of the respiratory rate between the two systems was very small. This paper shows that the air-mattress system can be a reliable non-invasive respiratory monitoring system to detect simple abnormalities in breathing, such as respiration rate and hypopnoeas.

A new asthma severity index: a predictor of near-fatal asthma?

Bronchial hyperresponsiveness (BHR), measured as the provocative dose of inhaled histamine or methacholine required to produce a 20% fall in forced expiratory volume in one second (FEV1) (PD20), is widely used as one of the indices of asthma severity. Excessive bronchoconstriction, reflected by the maximal percentage fall in forced vital capacity (FVC) at PD20 (deltaFVC %) during BHR testing, is considered to be the most important pathophysiological determinant in fatal asthma. The present study hypothesized that an index which combines both the ease of airway narrowing and excessive bronchoconstriction, deltaFVC %/log(PD20), may be better in assessing asthma severity, especially in those at risk of near-fatal attacks. The dose-response curves of 46 asthmatics who underwent methacholine challenge testing were studied. Group 1 (n=14) patients had mild disease, Group 2 (n=21) had moderate disease and Group 3 (n=11) had severe disease, as classified according to the Global Initiative for Asthma. Nine patients had prior intubation for near-fatal asthma. deltaFVC %/log (PD20) was better than deltaFVC % and PD20 in categorizing patients into the three severity groups (p<0.0001), but more importantly, it was able to discriminate patients with previous intubation from those without (p=0.04). It also correlated better with FEV1 (% predicted), frequency of symptoms and inhaled steroid requirement than either index alone. It is concluded that the percentage fall in forced vital capacity/log of the provocative dose causing a 20% fall in forced expiratory volume in one second combines information on the ease and excessive degrees of airway narrowing in asthma. This new index may be better at assessing asthma severity and in discriminating those at risk of near-fatal attacks.

Factors associated with acute health care use in a national adult asthma management program

BACKGROUND The use of acute health care resources for asthma is considerable. Disease severity is an established risk factor, but ethnicity and health care factors are less well studied. OBJECTIVE To investigate the independent associations of ethnicity and health care factors with acute resource use for asthma. METHODS Longitudinal data from a national adult asthma management program providing universal access to care were analyzed. Outcome measures were unscheduled physician visits with urgent nebulization, emergency department (ED) visits, and hospitalizations. RESULTS In multivariate analyses, markers of disease severity were found to be significantly associated with all acute resource use. After controlling for disease severity, ethnicity was associated with increased risk of all acute resource use; Indian (vs Chinese) ethnicity was associated with increased risk of unscheduled physician visits (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.03-1.70), ED visits (HR, 1.61; 95% CI, 1.12-2.32), and hospitalizations (HR, 1.49; 95% CI, 1.03-2.16). Malay ethnicity was associated with unscheduled physician visits (HR, 1.30; 95% CI, 1.01-1.68) and ED visits (HR, 1.55; 95% CI, 1.09-2.19). Default of follow-up appointments was associated with unscheduled physician visits (HR, 1.47; 95% CI, 1.08-2.00), ED visits (HR, 2.35; 95% CI, 1.59-3.45), and hospitalizations (HR, 1.74; 95% CI, 1.09-2.76). Poor inhaler technique was associated with ED visits (HR, 1.86; 95% CI, 1.05-3.30) and smoking with unscheduled physician visits (HR, 1.38; 95% CI, 1.09-1.76). CONCLUSIONS In addition to markers of asthma severity, ethnicity, smoking, discontinuity of care, and self-care behavior are risk factors for acute resource utilization and represent target groups and elements of asthma intervention for improving asthma outcomes.

Timeliness of diagnosing lung cancer: Number of procedures and time needed to establish diagnosis

Abstract To study number of procedures and time to diagnose lung cancer and factors affecting the timeliness of clinching this diagnosis. Retrospective cohort study of lung cancer patients who consecutively underwent diagnostic bronchoscopy in 1 year (October 2013 to September 2014). Out of 101 patients diagnosed with lung cancer from bronchoscopy, average time interval between first abnormal computed tomogram (CT) scan-to-1st procedure, 1st procedure-to-diagnosis, and 1st abnormal CT scan-to-diagnosis was 16 ± 26, 11 ± 19, and 27 ± 33 days, respectively. These intervals were significantly longer in those requiring repeat procedures. Multivariate analysis revealed inconclusive 1st procedure to be the predictor of prolonged (>30 days) CT scan to diagnosis time (P = 0.04). Twenty-nine patients (28.7%) required repeat procedures (n = 63). Reasons behind repeating the procedures were inadequate procedure (n = 14), inaccessibility of lesion (n = 9), inappropriate procedure (n = 5), mutation analysis (n = 2), and others (n = 2). Fifty had visible endo-bronchial lesion, 20 had positive bronchus sign, and 83 had enlarged mediastinal/hilar lymph-nodes or central masses adjacent to the airways. Fewer procedures, and shorter procedure to diagnosis time, were observed in those undergoing convex probe endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) (P = 0.04). Most patients exhibit enlarged mediastinal lymph node or mass adjacent to the central airway accessible by convex probe EBUS-TBNA. Hence, combining it with conventional bronchoscopic techniques such as bronchoalveolar lavage, brush, and forceps biopsy increases detection rate, and reduces number of procedures and time to establish diagnosis. This may translate into cost and resource savings, timeliness of diagnosis, greater patient satisfaction, and conceivably better outcomes.

Predicting mortality among older adults hospitalized for community‐acquired pneumonia: An enhanced Confusion, Urea, Respiratory rate and Blood pressure score compared with Pneumonia Severity Index

Background and objective:  Pneumonia Severity Index (PSI) predicts mortality better than Confusion, Urea >7 mmol/L, Respiratory rate >30/min, low Blood pressure: diastolic blood pressure <60 mm Hg or systolic blood pressure <90 mm Hg, and age >65 years (CURB‐65) for community‐acquired pneumonia (CAP) but is more cumbersome. The objective was to determine whether CURB enhanced with a small number of additional variables can predict mortality with at least the same accuracy as PSI.

Use of bilevel positive airway pressure ventilatory support for pathological flail chest complicating multiple myeloma

Multiple myeloma is a common disease that universally involves the skeletal system. Although rib involvement may occur, the development of pathological flail chest is rare. We describe the treatment and course of this condition in an elderly female, and the use of the bilevel positive airway pressure (BiPAP) ventilatory system in providing pneumatic stabilization, while definitive chemotherapy was given to heal the pathological fractures. Our experience with this patient suggests that, despite its dramatic clinical manifestation, the association of flail chest with multiple myeloma may not predict a poor prognosis. We have also found that pneumatic stabilization can be achieved by using the bilevel positive airway pressure ventilatory support through a tracheostomy.

Pleural LDH as a prognostic marker in adenocarcinoma lung with malignant pleural effusion

AbstractTo study the performance of serum and pleural lactate dehydrogenase (LDH) level in predicting survival in patients with adenocarcinoma lung presenting with malignant pleural effusions (MPE) at initial diagnosis.Retrospective cohort study of the patient hospitalized for adenocarcinoma lung with MPE in year 2012.Univariate analyses showed lower pleural fluid LDH 667 (313–967) versus 971 (214–3800), P = 0.04, female gender 9 (100%) versus 27 (41.5%), P = 0.009, never smoking status 9 (100%) versus 36 (55.3%), P = 0.009, and epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) therapy 8 (89%) versus 26 (40%), P = 0.009 to correlate with survival of more than 1.7 year versus less than 1.7 year. In multivariate analysis, low pleural fluid LDH and female gender maintained significance. The pleural LDH level of ⩽1500 and >1500 U/L discriminated significantly (P = 0.009) between survival.High pleural LDH (>1500 IU/L) predicts shorter survival (less than a year) in patients with adenocarcinoma lung presenting with MPE at the time of initial diagnosis. This marker may be clinically applied for selecting therapeutic modality directed at prevention of reaccumulation of MPE. Patients with low pleural LDH may be considered suitable for measures that provide more sustained effect on prevention of reaccumulation such as chemical pleurodesis or tunneled pleural catheter.

Can EGFR-Tyrosine Kinase Inhibitors (TKI) Alone Without Talc Pleurodesis Prevent Recurrence of Malignant Pleural Effusion (MPE) in Lung Adenocarcinoma

Abstract: Background and Objective: Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitors (EGFR-TKIs) are effective against lung adenocarcinoma. However, limited data is available assessing the effectiveness of EGFR-TKI use in preventing re-accumulation of MPE. To our knowledge, there is no literature on comparison of talc pleurodesis with EGFR-TKIs alone on re-accumulation of MPE in Asian population. We investigated if EGFR-TKI therapy for advanced lung adenocarcinoma with malignant pleural effusion (MPE) is also successful in preventing pleural fluid re-accumulation following initial drainage. Methods: An observational cohort study of patients with lung adenocarcinoma and MPE in the year 2012 was conducted. Results: 70 patients presented with MPE from lung adenocarcinoma. Fifty six underwent EGFR mutation testing of which 39 (69.6%) had activating EGFR mutation and 34 (87.1%) received TKI. 20 were managed by pleural fluid drainage only whereas 14 underwent talc pleurodesis following pleural fluid drainage. Time taken for the pleural effusion to re-accumulate in those with and without pleurodesis was 9.9 vs. 11.7 months, p=0.59 respectively. More patients (n=10, 25.6%) with activating EGFR mutation presented with complete opacification (white-out) of the hemithorax compared to none without activating EGFR mutation (p=0.02). Conclusion: In TKI eligible patients, early talc pleurodesis may not confer additional benefit in preventing re-accumulation of pleural effusion and may be reserved for non-adenocarcinoma histology, or EGFR negative adenocarcinoma. Complete opacification of the hemithorax on presentation may serve as an early radiographic signal of positive EGFR mutation status.