Spirometry quality control: man versus machine

OBJECTIVE: To compare the efficacy of local quality control (QC) of BOLD (Burden of Obstructive Lung Disease) Trinidad and Tobago study with spirometer machine quality grades as well as with BOLD Pulmonary Function Reading Centre QC standards at Imperial College, London. METHODOLOGY: Quality of the randomly chosen two hundred spirometries was independently assessed by the local team based on the 2005 ATS/ERS spirometry standards. Central QC quality assessment results were blinded to the local team. However, the machine quality grades were readily available to both the central and local teams during interpretation. Local and machine QC performances were correlated with the central QC which was taken as the gold standard for this study. RESULTS: According to central QC, 17.5% of the spirometries were declared as unacceptable. The noted common errors were prolonged peak expiratory flow time(14.5%), submaximal blasts (11.5%), variable efforts (11%) and poor reproducibility (10%). Cronbach’s alpha assessment revealed an overall reliability of 0.82 and a correlation of 0.73 between central and local QC. The correlation between central and machine QC was poor(0.548). Local QC exhibited 89.1% sensitivity and 94.3% specificity relative to the central QC. Though the machine QC displayed a better sensitivity (97.6%), its specificity was significantly lower 45.7%). CONCLUSION: Local QC was effective when compared with the central QC and executed better performance than the machine’s QC. This expertise can now be utilized for the future spirometry based local research studies. Due to limitations in identifying various errors, machine QC should not solely be used as the determinant of acceptability.

Effects of exacerbations and seasonality on exhaled nitric oxide in COPD

Exhaled nitric oxide (eNO) appears to be associated with airway inflammation seen in chronic obstructive pulmonary disease (COPD). The present authors studied the effects of exacerbation, season, temperature and pollution on eNO. eNO was measured seasonally and at exacerbations in 79 outpatients suffering from COPD (mean forced expiratory volume in one second = 42%). The effects of exacerbation symptoms, physiological and environmental parameters were analysed. Stable eNO levels were correlated positively with arterial oxygen tension. Median levels were found to be lower in smokers (5.3 ppb) than in ex- or nonsmokers (6.8 ppb). Levels were higher during October to December (6.9 ppb) than in April to June (4.6 ppb). Levels were also higher during 68 exacerbations in 38 patients (7.4 ppb) than in stable conditions (5.4 ppb), independent of the effects of smoking. The rise in eNO was greater in exacerbations that were associated with colds, a sore throat or dyspnoea combined with a cold. In conclusion, exhaled nitric oxide levels were higher in colder weather and in the autumn, perhaps related to the increased prevalence of viral infection at this time of year. The levels were lower in more severe chronic obstructive pulmonary disease. Exhaled nitric oxide levels were raised at the onset of exacerbation, particularly in the presence of a cold.

Significance of fever in Jamaican patients with homozygous sickle cell disease

OBJECTIVE: To investigate the cause and outcome of high fever in Jamaican children with homozygous sickle cell disease. DESIGN: Retrospective review of febrile episodes in a three year period (1 September 1993 to 31 August 1996). SETTING: Sickle Cell Clinic, an outpatient clinic in Kingston run by the Medical Research Council Laboratories (Jamaica). PATIENTS: Patients with homozygous sickle cell disease under 17 years of age presenting with an anxillary temperature o 39.0§c (102.4§F). MAIN OUTCOME MEASURES: Diagnosis, death. RESULTS: There were 165 event in 144 patients (66 (45.8 percent) boys) with a median age of 6.1 years. Bacteraemia was found in 10 (6.1 percent) events (three Streptococcus pneumoniae, two Haemophilus influenzae type b, two Salmonella sp, one Escherichia coli, one Enterobactor sp, and one Acinetobacter sp), and urinary tract infections in four (2.4 percent). All cultures of cerebrospinal fluid were sterile. Acute chest syndrome occured in 36 (21.8 percent) events. A painful crisis was associated with 45 (27.3 percent) events and was the only pathology identified in 20 events (12.1 percent). Hospital admission was necessary in 66 cases including all those with bacteraemia and 31 with acute chest syndrome. There were two deaths: a 5 year old boy with septic shock associated with H influenzae septicaemia, and a 3 year old boy with the acute chest syndrome. CONCLUSIONS: Painful crisis and acute chest syndrome were the most common complications associated with high fever, but other important associated features included bacteraemia and urinary tract infection. Enteric Gram negative organisms accounted for 50 percent of positive blood cultures. (AU)

Pneumoconioses diagnosed at the National Chest Hospital, characteristics of patients and their environment, 1980-1989

The primary focus of the study is the prevalence of pneumoconioses diagnosed at the National Chest Hospital during the decade 1980-1989, with a view to determining the characteristics of the patients and the characteristics of the environment to which patients had been exposed. It is hoped that the finding will give a general picture of the status of the disease in Jamaica. The methodology used for data collection was primarily the perusal of dockets at the hospital. A total of thirty cases were diagnosed over the decade representing four disease in the category namely, pulmonary fibrosis, asbestosis, anthracosis and silicosis. Owing to the rarity of the diseases and consequently the few cases diagnosed over the period the data did not lend itself to certain statistical analyses. The cases diagnosed were more frequent among males in the older age groups. Most cases were also from Kingston due to the fact that it is the primary urban centre in Jamaica. Based on occupation, it was easy to fathom why some persons were diseased. (AU)

Pathology of the lungs in childhood malnutrition in Jamaica: light and electron microscopy

The autopsy records of 115 children with severe protein-energy malnutrition were reviewed. Sections of the lung histology showed evidence of bacterial pneumonia in 49 percent of cases. An additional 18 percentshowed bronchitis, bronchiolitis or interstitial pneumonitis. Aspiration of gastric contents was evident in 10 percent of cases; 6 percent showed pulmonary oedema and congestion. In the remaining cases, no lung pathology was identified (17 percent). In 8 cases, rapid autopsy examination permitted fixation of lung tissue for electron microscopy. These included 4 cases of bronchopneumonia, one of which was associated with viral pneumonia. Another interstitial pneumonitis, probably of viral aetiology, was also studied. Both these virus-associated cases showed loss of type I pneumocytes and hyperplasia of type II pneumocytes. Another patient with herpes simplex hepatitis showed necrotic emboli in pulmonary capillaries with virions, as well as colonies of interstitial bacteria. One patient with acute pulmonary oedema displayed severe endothelial cell swelling on electron microscopy. In one case, there was no evidence of respiratory changes, apart from desquamation of type I pnuemocytes. Useful information can be obtained on the fine structure of the lung, using samples taken soon after death. (AU)

Analysis of 81 cases of acute chest syndrome in adult patients with sickle-cell disease in Curacao - abstract

All patients more than 14 years old with sickle-cell disease (SCD) discharged from hospital with a diagnosis of acute chest syndrome (ACS) from January, 1980 to December, 1981 were enrolled in this retrospective study. Data were collected from patients' records to investigate frequency, risk factors, effect of intravenous heparin and outcome in ACS. There were 109 adult SCD patients of whom 53 (49 per cent) were admitted for 81 episodes of ACS. Hb SS and Hb SC patients were affected equally often. Chest pain was the most frequent presenting symptom (64 per cent) and 91 per cent of patients had pulmonary abnormalities on physical examination, but only 45 per cent had radiological evidence of ACS at diagnosis. Forty-three per cent of sputum cultures grew pathogenic micro-organisms. The overall case-fatality rate was 6 per cent. All 5 non-survivors were female Hb SS patients. Intention-to-treat analysis revealed no benefit of intravenous heparin on outcome (mortality 5 per cent versus 11 per cent in non-heparin-treated patients, p = 0.3), hospital stay (p = 0.7) or duration of hypoxaemia (p = 0.4) (AU)

The clinical features of sickle cell disease

Evidence from structural studies of DNA suggest that the sickle cell mutation has arisen on at least three separate occasions in Africa and as a fourth independent mutation in the Eastern Province of Saudi Arabia or India. The pathophysiology of sickle cell disease is essentially similar in these different areas although the frequency and severity of complications may vary between areas. Generally, the chronic haemolysis and resulting anaemia is well tolerated, although serious morbidity and occasionally mortality may be associated with the aplastic crisis or cholelithiasis. Exacerbation of anaemia below steady state levels occurs with chronic glomerular damage and renal failure, especially in older patients. Most of the morbidity of the disease arises from bone marrow necrosis in the painful crisis or from vaso-occlusive manifestation. Changes in the splenic circulation results in life-threatening episodes of acute splenic sequestration, the chronic morbidity of hypersplenism, and splenic dysfunction renders children prone to pneumococcal septicaemia. Chronic organ damage contributes to chronic leg ulceration in adolescence and progressive renal,pulmonary,and occasionally cardiovascular impairment in later life. The clinical spectrum of homozygous sickle cell disease varies widely between patients. Factors contributing to this variability include alpha-thalassaemia,persistence of high HbF levels, haematology, social circumstances, and geographical and climatic variation. Many of the causes of mortality may be prevented or more effectively treated,leading to increased survival and an increased quality of life in affected subjects (AU)

Fatal metastatic calcification in a patient with HTLV-I-associated lymphoma

Metastic calcification of the heart, lungs and kidneys is described in a 42-year-old male who had an HTLV-I-associated lymphoma. This fatal complication of HTLV-I-associated lymphoma has been infrequently reported, and the case in question is the first to be recorded in the Caribbean, where HTLV-I is common. Aggressive therapy of hypercalcaemia should be instituted early in its genesis in these lymphomas, so as to avoid its fatal outcome (AU)

Cardiac involvement in polymyositis: a clinicopathologic study of 20 autopsied patients

Cardiac involvement in polymyositis was investigated in 20 autopsied cases. Clinically, 13 of 18 patients had abnormal electrocardiograms, and 9 of the 20 patients had previous evidence of congestive heart failure. Histologically documented myocarditis was detected in 6 patients (4 with congestive heart failure and 2 without), 4 of whom also had small vessel disease of the myocardium. Patients with polymyositis may have a cardiopathy in the absence of overt myocardial inflammatory disease. (AU)

Hodgkin's disease and hypertrophic pulmonary osteoarthropathy

A case of mediastinal Hodgkin's disease associated with hypertropic pulmonary osteoarthropathy (HPOA) is described. The lung lesions almost completely cleared and the HPOA disappeared with adequate doses of radiation therapy (AU)

Familial pulmonary emphysema - abstract

Two brothers, aged 39 years and 37 years, of African origin, attending the University Hospital of the West Indies, have been shown to have familial pulmonary emphysema with a severe depletion in serum alpha - 1 antitrypsin levels, the main proteinase inhibitors in human serum. Previous reports of this disorder have come from the United States of America and Europe. This is the first report from the Caribbean, and the second of its occurrence in subjects of African descent. The elder brother, who is the worse affected, noted breathlessness from 27 years of age, and is now totally disabled. The younger brother, became dyspnoeic at 32 years and now has to stop for breath after walking 100 yard, Both have a chronic cough with intermittent sputum production. Initially they were heavy smokers, but dyspnoea has forced the younger brother to reduce his consumption, and the elder brother to give up the habit. Chest radiographs and , in the younger brother lung volume and pulmonary gas transfer studies confirm emphysema. The elder brother is too ill to have lung function tests. The disease is inherited as a Mendelian recessive disorder. Serum alpha - 1 antitrypsin levels of both brothers are less than 25 mg per cent indicative of the homozygous state. The mother, one brother, and all three of the patients' children are heterozygotes for the gene with levels between 25 mg and 150 mg per cent. One brother and two sisters, and all their children have normal levels in excess of 150 mg per cent. The father died some years ago, but had no history of lung disease. The nature of the association between pulmonary emphysema and low levels of serum alpha - 1 antitrypsin remains uncertain (AU)

Clinical features of pulmonary lesions in sickle cell anaemia

Acute pulmonary diseases in patients with sickle cell anaemia are usually diagnosed as pneumonia, but in our experience their rate of resolution and clinical course is different from pneumonia occuring in patients with normal haemoglobins. To confirm this we analysed the clinical course of these clinical episodes in a group of patients with sickle cell anaemia and compared them with a control group of patients with acute lobar pneumonia (AU)

Thoracic surgical trauma - abstract

The subject of this paper is based on the experiences during a five-year period of treating patients with respiratory distress in a general surgical unit in San Fernando, Trinidad. These patients required to have surgical intervention by one form or other. They were cases of thoracic surgical trauma. Of 120 cases of thoracic surgical trauma, 35 cases required some form of intervention. There were five cases of stove-in chest, two (2) cases of haemopericardium, five (5) cases of haemothorax and nineteen (19) cases of pneumothorax. Most of these were associated with blunt trauma, whilst the rest were associated with pellets, bullets or stabbing weapons. In the cases of pulmonary and/or pleural abnormalities, it is the resulting derangement of physiology which cause severe and urgent symptoms. These are mainly due to collapse of lung, shift of mediastinum, decrease in circulation of oxygenated blood. In the addition, there may be injury and fracture of the bony thoracic cage, which will aggravate such symptoms. When such bony injury occurs in two (2) places and over a large extent of the chest wall, stove in chest ensues. In cases of haemopericardium, the classical symptoms of cardiac tamponade ensue. These include rising venous pressure, falling arterial pressure and a quit heart. The diagnosis of the exact abnormality is most important and urgent as a satisfactory outcome depends on accurate diagnosis and treatment. Considerable use is made of X-rays and good X-rays are most important. As accurate as these may be, however, great reliance is placed upon the results of aspirating the pleural and/or pericardial cavities. The resulting aspirate with the interpretations of X-rays form the basis of accurate diagnosis. The use of indwelling intercostal catheter and open surgery for the primary condition or for its complication are used. Tracheostomy and internal fixation of the bony chest wall with various forms of tractions are utilized for the case of stove-in chest(AU)

The pathology of sickle cell anaemia in Jamaican adults over 30

The pathological findings at autopsy in 7 patients over the age of 30 with sickle cell anaemia are described and discussed. The 3 youngest died of well recognized complications of sickle cell anaemia. The 4 older patients, all over 50, had been remarkably free of direct complications and died of disease which could have been unrelated to sickle cell anaemia. Cirrhosis and chronic nephritis were not seen. Pulmonary vascular disease was seen in 2 patients but its significance in relation to sickle cell anaemia has not yet been established in Jamaican patients.(AU)

Bagassosis: an epidemiological, environmental, and clinical survey

An epidemiological and environmental survey of 170 bagasse workers employed by a raw sugar producing company in Trinidad was carried out in order to assess the prevalence of respiratory symptoms and to determine if exposure to bagasse was associated with alterations in ventilatory capacity. The epidemiological survey failed to reveal a significantly increased prevalence of respiratory symptoms in the more exposed group but showed that the group of Indian workers who were regularly and continously exposed to bagasse had a significantly lower ventilatory capacity than the control group. This diminished ventilatory capacity was demonstrated despite negligible dust concentrations in the plant. However, the possibility that persistence exposure to low concentrations of bagasse may be the cause must be considered. During a five-year period, 17 patients with bagassosis were seen, the clinical picture being similar to that described in extrinsic allergic alveolitis from other causes. The systematic variations demonstrated in some indices of ventilatory function in different racial groups is discussed.(AU)

Heart weight of Jamaicans: autopsy study of normal cases of hypertension and chronic lung disease

The heart weight and the weights of the component parts have been measured in a group of 126 Jamaicans of African origin on whom autopsy was performed at the Pathology Department of the University of the West Indies. This series comprised 58 normal cases, 46 cases of hypertension, and 22 cases of chronic lung disease. The mean heart weight for normal males was 294.5 g and for females 258.5 g. These figures are similar to those reported from Uganda but less than those from Britain and North America. The differences in heart weight are probably correlated with difference in body size. Total heart weight in the hypertensives was greater than in normals because of left ventricular hypertrophy. In chronic lung disease total heart weight was greater than that of normals due to enlargement of the right ventricle and of the combined atria. Right ventricular weight was also increased in cases of hypertension. (AU)

Neonatal death and massive pulmonary haemorrhage in Jamaica

Examinations were carried out on 27 newborn infants dying with massive pulmonary haemorrhage. Pulmonary haemorrhage occurred in 8 percent of neonatal deaths in this hospital: 52 percent of cases died early in the neonatal period and 48 percent later. Anoxia was considered to be the main causal agent in the majority of early cases. In the later cases several factors were considered responsible.(AU)

Studies of pulmonary alveolar microlithiasis and pulmonary alveolar proteinosis

A case of pulmonary alveolar microlithiasis and a case of pulmonary alveolar proteinosis in West Indian patients are described. A course of therapy with a chelating agent produced no roentgenologic improvement in alveolar microlithiasis. The pathology of these diseases is briefly reviewed, and the possible interrelations of pulmonary alveolar microlithiasis, pulmonary alveolar proteinosis, and pulmonary corpora amylacea are discussed (Summary)