Efficacy and safety of inhaled nebulized sodium nitrite in asthmatic patients.

BACKGROUND: Nitrite is a physiologic nitric oxide (NO) derivative that can be bioactivated to NO. NO has been shown to attenuate airway inflammation and enhance the anti-inflammatory effect of corticosteroids in the animal model of asthma. Here, we aimed to investigate the efficacy and safety of inhaled sodium nitrite as add-on therapy with inhaled corticosteroid (ICS) in adult patients with persistent asthma. METHODS: In protocol 1, 10 asthmatic patients were administered a single dose of nebulized 15-mg sodium nitrite to assess safety, effect on lung function, and pharmacokinetics of nitrite within 120 min. In protocol 2, 20 patients were randomly assigned to a nitrite (15 mg twice daily) group or a placebo group to assess the efficacy over 12 weeks. The primary outcome was the forced expiratory volume in 1 s (FEV1). The secondary outcomes were other lung function parameters, unplanned asthma-related visits at the emergency department (ED) or outpatient department (OPD), admission days, asthma control test (ACT), and safety. RESULTS: Nebulized sodium nitrite had neither acute adverse effect nor effect on lung function test within 120 min. No blood pressure change was seen. At week 12, FEV1 increased in the nitrite group, whereas there was no change in the placebo group. There were 5 events of asthma exacerbation, 4 ED visits, and one unplanned OPD visit in the placebo group, but none of these was noted in the nitrite group. There was no change in ACT scores in both groups. No adverse event was reported during 12 weeks in the nitrite group. There was no change in methemoglobin levels and sputum inflammatory markers. CONCLUSION: From our pilot trial, nebulized sodium nitrite is safe in asthmatic patients, and shows the potential to reduce asthma exacerbation compared with placebo.

Prevalence of small airways dysfunction in asthma with- and without-fixed airflow obstruction and chronic obstructive pulmonary disease.

BACKGROUND: Small airways dysfunction (SAD) is not uncommon in asthma without fixed airflow obstruction (FAO). OBJECTIVE: We aimed to determine if SAD in non-FAO asthma is different from FAO-asthma and COPD. METHODS: Cases of obstructive airway diseases who underwent spirometry, plethysmography, and impulse oscillometry [resistance at 5 Hz (R5) and at 20 Hz (R20), peripheral resistance (R5-R20), and reactance area (AX)] were reviewed, and classified as; 1) COPD, 2) FAO-asthma, and 3) non-FAO asthma. FAO was defined as post-bronchodilator (post-BD) FEV1/ FVC < 0.7. SAD was considered if 1) RV/TLC ≥ 40%, or 2) post-BD R5-R20 ≥ 0.075 kPa.L-1s. RESULTS: A total of 73 patients (22 COPD, 24 FAO-asthma, and 27 non-FAO asthma) were analyzed. RV/TLC ratio was higher in FAO-asthma and COPD (45 ± 5% and 42 ± 8%) than in non-FAO asthma (32 ± 8%), p < 0.001. Post-BD values of R5-R20 and AX (median; range) were higher in FAO-asthma (0.17; 0.08, 0.47, 13.24; 6.52, 82.11) than in non-FAO asthma (0.11; 0.03, 0.23, 8.63; 2.40, 22.02), p = 0.007 and p = 0.017, respectively. The prevalence of SAD among diagnosis group by RV/TLC criterion was different (95%, 59%, and 15% in FAO-asthma, COPD, and non-FAO asthma, p < 0.001), but those were not observed by R5-R20 criterion (95%, 68%, and 77%, p = 0.052). CONCLUSIONS: SAD in non-FAO asthma was less prevalent than FAO-asthma and COPD.

Oxygen Uptake and Lactate Kinetics in Patients with Chronic Obstructive Pulmonary Disease during Heavy Intensity Exercise: Role of Pedaling Cadence.

Oxygen uptake slow component ([Formula: see text]sc) is associated with lactate accumulation, likely a contribution of poorly oxidative muscle fibers. We aimed to test the hypothesis that higher muscle tension during slow pedaling rates would yield more prominent [Formula: see text]sc in healthy subjects, but not in COPD patients. Eight severe COPD patients and 8 age-matched healthy individuals performed 4 rest-heavy exercise transitions at 40 and 80 RPM. Work rates at the two cadences were balanced. Venous blood was sampled for measurement of lactate concentration at rest and every 2 minutes until the end of exercise. [Formula: see text] kinetics were analyzed utilizing nonlinear regression. [Formula: see text] phase II amplitudes at the two cadences were similar in both groups. In healthy individuals, [Formula: see text]sc was steeper at 40 than 80 RPM (46.6 ± 12.0 vs. 29.5 ± 11.7 mL/min2, p = 0.002) but not in COPD patients (16.2 ± 14.7 vs. 13.3 ± 7.6 mL/min2). End-exercise lactate concentration did not differ between cadences in either group. In healthy individuals, greater slow-cadence [Formula: see text]sc seems likely related to oxidative muscle fiber recruitment at higher muscular tension. COPD patients, known to have fast-twitch fiber predominance, might be unable to recruit oxidative fibers at high muscle tension, blunting [Formula: see text]sc response.

Long-term effectiveness of omalizumab treatment in Thai severe asthmatic patients: A real-life experience.

BACKGROUND: To evaluate long-term effectiveness of omalizumab in 'real-life' setting of Thai asthmatic patients. METHODS: We conducted multi-center, observational study in severe asthma patients who received omalizumab in Thailand. Outcomes were asthma exacerbation (hospitalization and ER visit), asthma control test (ACT), and daily ICS dose. Data were evaluated at baseline, 16 Week, and 52 Week. RESULTS: A total of 78 patients received omalizumab treatment (average duration 16.9 months with range 16 weeks-2 years). The mean annualized rate of exacerbations was reduced from baseline (3.79) at Week 16 (3.54) and Week 52 (1.16), (p<0.05), respectively. The mean hospitalization rate was reduced from 0.49 in previous year to 0.15 at Week 16 and 0.19 at Week 52. A reduction in ER visit rates was observed at Week 16 (0.15) and Week 52 (0.97) respectively from baseline (1.44) (p<0.05). The ACT score increased from 15.4 at baseline to 20.6 at Week 16 (p<0.001) and increased to 21.5 at Week 52 (p<0.001). The number of patients with controlled asthma (ACT≥20) increased from 16 of 51 at baseline to 32 of 45 at Week 16 and 25 of 32 at week 52, respectively. The median daily dose of ICS equivalent to fluticasone was reduced from baseline 680 mcg to 500 mcg at Week 52. In all, 22 patients discontinued omalizumab after 1 year. Six patients who discontinued omalizumab were restarted due to relapse of symptoms. CONCLUSIONS: These data confirms the effectiveness of one-year duration of omalizumab treatment in Thai severe asthmatic patients. Furthermore, 27% of patients who discontinued treatment required restarting due to relapse of symptoms.

Validity and reliability of the Thai version of the leicester cough questionnaire in chronic cough.

BACKGROUND: Chronic cough is a common problem potentially disturbing the quality of life (QoL) of coughers. The Leicester Cough Questionnaire (LCQ), previously developed in England, is a validated, self-completed QoL instrument for assessment of chronic cough. This study aimed to develop a Thai version of the LCQ (LCQ-T) and assess its validity and reliability among adult Thai patients with subacute to chronic cough. METHODS: A total of 146 patients with a cough lasting for more than 3 weeks consented to participate in this study and self-administered the LCQ-T, together with the following 3 instruments: Borg Cough Scale (BCS), Short Form-36 (SF-36), and Hospital Anxiety Depression Scale (Thai-HADS). The LCQ-T was developed by applying a forward-backward translation approach. The LCQ-T comprises 19 items divided into 3 domains: physical (8 items), psychological (7 items), and social (4 items). To validate the LCQ-T, concurrent validity, internal consistency reliability, and test-retest reliability were assessed. RESULTS: Participants included 96 women and 50 men with a mean (SD) age of 59.6 (14.4) years. The concurrent validity comparing LCQ-T to BCS yielded statistically significant Pearson correlation coefficients (r= -0.74, P<0.05). The correlation coefficients for SF-36 and Thai-HADS were also significant. The LCQ-T demonstrated very good internal consistency in all domains and the overall scale, with the Cronbach's alpha coefficients ranging from 0.89 to 0.94. The 3-day repeatability of the LCQ-T in 25 clinically stable patients was high with the intra-class correlation coefficients ranging between 0.81 and 0.90. CONCLUSION: LCQ-T is a valid and reliable cough-specific instrument for assessing symptoms and QoL of adult Thai patients with subacute to chronic cough.

Work- and travel-related physical activity and alcohol consumption: relationship with bone mineral density and calcaneal quantitative ultrasonometry.

A number of healthy workers rarely exercise because of a lack of time or resources. Physical activity related to work and everyday travel may be more feasible, but evidence of its beneficial effect on bone health is scarce. We assessed if this form of physical activity was associated with higher bone mineral density (BMD) and stiffness index (SI) when adjusted for recreational physical activity, age, body mass index, smoking, alcohol consumption, education, and serum level of 25-hydroxyvitamin D. Healthy workers, aged 25-54 yr, of the Electricity Generating Authority of Thailand were surveyed. The outcomes were BMD (lumbar spine, femoral neck, and total hip) and calcaneal SI. Physical activity was estimated using the global physical activity questionnaire and considered active when >600 metabolic equivalent tasks (min). Of 2268 subjects, 74% were men. Active male subjects had significantly higher BMD at the femoral neck and total hip (p<0.005). However, the association was not significant with male lumbar spine BMD, male SI, or any bone parameters in women (p>0.05). In men, work and travel physical activity seems beneficial to male bone health; hence, it should be encouraged. Furthermore, smoking appeared harmful while moderate alcohol consumption was beneficial.

Interleukin-2 levels in exhaled breath condensates, asthma severity, and asthma control in nonallergic asthma.

There was evidence that interleukin (IL)-2 and IL-10 in the airways play roles in regulating the asthmatic inflammatory response. The purpose of this study was to measure the levels of these cytokines in exhaled breath condensates (EBCs) from asthmatic airways and their correlation with a clinical assessment of asthma severity. The levels of IL-2 and IL-10 in EBC, Asthma Control Test (ACT) score, and the forced expiratory volume in 1 second (FEV1) were studied in 28 steroid-free asthmatic patients and 10 healthy volunteers. The results were analyzed according to their allergic status, asthma severity, and body weight. The correlations between IL-2 and IL-10 levels, percent predicted FEV1, ACT score, and body mass index were also determined. Both IL-2 and IL-10 levels in EBC significantly increased in asthmatic patients, especially in patients with moderate-to-severe persistent asthma, compared with those in normal controls. However, the signification correlations between IL-2 levels and ACT (r = -0.684; p = 0.007), as well as with percent predicted FEV1 (r = -0.671; p = 0.009), were established only in patients with nonallergic asthma. The elevation of IL-2 levels in EBC in obese subjects was observed but was probably related to asthma severity. The levels of IL-2 and IL-10 in EBC increase in asthmatic patients but only IL-2 levels significantly correlate with the ACT score and percent predicted FEV1 in nonallergic asthma. Additional studies should be explored to confirm the reliability of ACT score as a predictor of inflammatory response in asthmatic airways. Clinical trial NCT01246414, http://www.clinicaltrials.gov.

Interferon-gamma release assays for diagnosis of latent TB infection in chronic kidney diseases and dialysis patients.

Introduction: Patients with chronic kidney disease (CKD), especially end-stage kidney disease (ESKD), are at risk of developing tuberculosis (TB). The prevalence and predictors of LTBI assessed by a high-sensitivity, high-specificity test such as an interferon-gamma release assay (IGRA) has not been thoroughly explored. Methods: All patients with CKD were prospectively recruited from September 2020 to November 2021 and retrospectively reviewed from December 2020 to November 2021. The prevalence of LTBI was determined using IGRA by CKD stage and dialysis type. Predictors of LTBI were assessed by logistic regression analysis. Results: In total, 199 patients with CKD were enrolled (102 prospectively, 97 retrospectively). Of these, 173 patients were evaluable (mean age, 53 ± 16 years; 44% male). Ninety-five (55%) patients had ESKD and were maintained on renal replacement therapy. Overall, 39 (22.5%) patients had LTBI with a prevalence of 25.0%, 12.5%, 25.0%, 25.0%, and 24.2% among patients with CKD stage 1, 2, 3a, 3b, and ESKD, respectively (p=0.89). Among patients with ESKD, the prevalence of LTBI was higher in those on hemodialysis than in those on peritoneal dialysis (28.9% vs. 5.3%, p=0.03). In the multivariable analysis of patients with ESKD, drinking alcohol was significantly associated with LTBI (odds ratio, 8.51; 95% confidence interval, 1.24-58.38; p=0.029), and hemodialysis was marginally associated with LTBI (odds ratio, 8.14; 95% confidence interval, 0.95-69.91; p=0.056). Conclusion: In TB-endemic settings, 20% of patients with CKD and 25% of patients with ESKD may have LTBI. Alcohol consumption and hemodialysis can help to identify high-risk patients with ESKD and potentially screen for LBTI.

Exercise-induced bronchoconstriction in rhinitis children without asthma.

BACKGROUND: Exercise-induced bronchoconstriction (EIB) is a condition that leads to limited participation in sports. Prevalence of EIB ranges from 5-20% in general population to 40 - 90% in asthmatic patients. But the prevalence among rhinitis children with EIB remains debatable. We aimed to determine the prevalence of EIB in nonasthmatic children with rhinitis. METHODS: A cross-sectional study was performed on 53 rhinitis patients without known asthma who attended the Pediatric Allergy Clinic between March 2009 and February 2010. They all underwent physical examination, skin prick test, pulmonary function tests and an exercise challenge test (ECT) on a treadmill. A positive ECT was defined as a decrease in FEV1 > 10% after exercise. RESULTS: The patients' mean age was 12.3 +/- 2.6 years. Most of them (60.4%) had moderate to severe persistent rhinitis. Eleven out of 53 patients (20.7%) had EIB. The peak time for occurrence of EIB was 10 minutes after exercise. Most of the EIB episodes observed were of mild degree. Patients who had persistent symptoms and a short duration of rhinitis treatment prior to the ECT day had more positive ECT results (72.7% vs. 28.6%, p 0.013, 0.2 years vs.1.9 years, p 0.012, respectively). The history (Hx) was not a reliable means of identifying children who had EIB (ECT+/Hx+ 54.6%, ECT-/Hx+ 54.8%). There was no significant relationship between baseline pulmonary function and the decline in FEV1 after exercise. CONCLUSION: The prevalence of EIB in rhinitis children without asthma is 20.7%. History, physical examination and pulmonary function are insufficient to diagnose EIB.

Effects of Oral Procaterol for Postinfectious Cough in Adults: Single-Centre, Randomized Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Persistent cough following an upper respiratory tract infection (URTI) is common in clinical practice. We investigated the effects of procaterol on cough-specific quality of life (QoL) and peripheral-airway function among adults suffering from postinfectious cough (PIC). METHODS: This was a prospective, randomized, double-blinded placebo-controlled trial (NCT02349919) conducted at a university hospital. Seventy-four non-asthmatic adults who had persistent post-URTI cough for ≥3 weeks were assessed by a physical examination, chest/paranasal sinus radiographs, spirometry, and impulse oscillometry (IOS) and were allocated to receive procaterol or placebo for 4 weeks. The Thai version of the Leicester Cough Questionnaire (LCQ-T), spirometry and IOS were assessed at baseline, 2 weeks, and 4 weeks. RESULTS: Mean LCQ-T total scores for the procaterol group (10.8) and placebo group (10.9) at baseline were not significantly different (P=0.821). After adjustment for baseline Borg Cough Scale score and post-nasal drip, the mean between-group difference was not significant for LCQ-T total score (-1.26; 95% confidence interval [CI], -2.69 to 0.17), physical domain score (-0.35; 95% CI, -0.76 to 0.06), psychological domain score (-0.53; 95% CI, -1.06 to 0.01), or social domain score (-0.38; 95% CI, -0.92 to 0.16). Large improvements in LCQ-T total score were reported in both groups after 2 weeks (procaterol, 4.21±2.73; placebo, 5.34±3.2), and 4 weeks (procaterol, 5.94±3.68; placebo, 7.07±3.44). No differences between groups were found in the mean changes of spirometry or IOS parameters after 4 weeks. CONCLUSION: Our study shows that procaterol is not effective in the treatment of PIC, in terms of improvement of cough-specific QoL or peripheral-airway function.

Initial diagnosis and successful treatment of pulmonary tumor embolism manifesting as the first clinical sign of prostatic adenocarcinoma.

Although pulmonary tumor embolism (PTE) is a well-recognized end-stage form of pulmonary metastases at postmortem examination, the entity is rarely the first clinical sign of prostate cancer. Diagnosis of this condition in patients who have no previous history of malignancy is a challenge. Herein, we reported a 79-year-old man presented with progressive, unexplained dyspnea on exertion. Microscopic PTE coinciding with pulmonary lymphangitic carcinomatosis were readily recognized based on the presence of multifocal dilatation and beading of the peripheral pulmonary arteries with thickening of the bronchial walls and interlobular septa on the initial thin-section chest CT images. Pathologic examination of the transbronchial lung biopsy specimen revealed tumor emboli occluding both the small muscular pulmonary arteries and lymphatic vessels. These tumor cells were positive for prostatic specific antigen on immunohistochemical staining. The final diagnosis of prostatic adenocarcinoma was confirmed. Remarkable clinical and radiographic improvement was achieved following bilateral orchiectomies and anti-androgen treatment.

Performance of real-time PCR and immunofluorescence assay for diagnosis of Pneumocystis pneumonia in real-world clinical practice.

BACKGROUND: PCR is more sensitive than immunofluorescence assay (IFA) for detection of Pneumocystis jirovecii. However, PCR cannot always distinguish infection from colonization. This study aimed to compare the performance of real-time PCR and IFA for diagnosis of P. jirovecii pneumonia (PJP) in a real-world clinical setting. METHODS: A retrospective cohort study was conducted at a 1,300-bed hospital between April 2017 and December 2018. Patients whose respiratory sample (bronchoalveolar lavage or sputum) were tested by both Pneumocystis PCR and IFA were included. Diagnosis of PJP was classified based on multicomponent criteria. Sensitivity, specificity, 95% confidence intervals (CI), and Cohen's kappa coefficient were calculated. RESULTS: There were 222 eligible patients. The sensitivity and specificity of PCR was 91.9% (95% CI, 84.0%-96.7%) and 89.7% (95% CI, 83.3%-94.3%), respectively. The sensitivity and specificity of IFA was 7.0% (95% CI, 2.6%-14.6%) and 99.2% (95% CI, 95.6%-100.0%), respectively. The percent agreement between PCR and IFA was 56.7% (Cohen's kappa -0.02). Among discordant PCR-positive and IFA-negative samples, 78% were collected after PJP treatment. Clinical management would have changed in 14% of patients using diagnostic information, mainly based on PCR results. CONCLUSIONS: PCR is highly sensitive compared with IFA for detection of PJP. Combining clinical, and radiological features with PCR is useful for diagnosis of PJP, particularly when respiratory specimens cannot be promptly collected before initiation of PJP treatment.

Pseudomembranous aspergillus tracheobronchitis superimposed on post-tuberculosis tracheal stenosis.

Pseudomembranous aspergillus tracheobronchitis superimposed on post-tuberculosis tracheal stenosis has not been previously reported. In the patient described in this case report, the airway obstruction was worsened by aspergillus infection which responded to antifungal therapy and debridement of pseudomembranous tissues by rigid bronchoscopic procedures. A silicone stent was successfully placed in the trachea to restore airway patency when there was no more evidence of tracheobronchial aspergillosis. This case raises the questions of whether, how and when to restore airway patency in patients with tracheal stenosis and concurrent aspergillus tracheobronchitis.

Efficiency of the home cardiac rehabilitation program for adults with complex congenital heart disease.

OBJECTIVE: We aimed to study the efficiency and safety of once-a-week outpatient rehabilitation followed by home program with tele-monitoring in patients with complex cyanotic congenital heart disease. DESIGN: Prospective nonrandomized study. METHOD: Patients who have been diagnosed either Eisenmenger's syndrome or inoperable complex cyanotic heart disease and able to attend 12-week cardiac rehabilitation program were included. Training with treadmill walking and bicycling under supervision at cardiac rehabilitation unit once-a-week in the first 6 weeks followed by home-based exercise program (bicycle and walking) with a target at 40%-70% of maximum heart rate (HRmax) at pretraining peak exercise for another 6 weeks was performed in the intervention group. Video and telephone calls were scheduled for evaluation of compliance and complication. Data from cardiopulmonary exercise testing (CPET) on cycle ergometry including peak oxygen consumption (peakVO2 ), oxygen pulse (O2 pulse), ventilatory equivalent for carbon dioxide (VE/CO2 at anaerobic threshold), constant work-rate endurance time (CWRET) at 75% of peak VO2 , and 6-minute walk distance (6MWD) were compared between baseline and after training by paired t test. RESULT: Of the 400 patients in our adult congenital heart disease clinic, 60 patients met the inclusion criteria. Eleven patients who could follow program regularly were assigned home program. There was a statistically significant improvement of CWRET, O2 pulse, and 6MWD after finishing the program (P = .003, .039, and .001, respectively). The mean difference of 6MWD change in the home-program group was significantly higher than in the control group (69.3 ± 47.9 meters vs. 4.1 ± 43.4 meters, P = .003). No serious adverse outcomes were reported during home training. CONCLUSION: Once-a-week outpatient hospital-based exercise program followed by supervised home-based exercise program showed a significant benefit in improvement of exercise capacity in adults with complex cyanotic congenital heart disease without serious adverse outcomes.

Assessment of proximal and peripheral airway dysfunction by computed tomography and respiratory impedance in asthma and COPD patients with fixed airflow obstruction.

OBJECTIVE: To ascertain: (i) if elderly patients with fixed airflow obstruction (FAO) due to asthma and chronic obstructive pulmonary disease (COPD) have distinct airway morphologic and physiologic changes; (ii) the correlation between the morphology of proximal/peripheral airways and respiratory impedance. METHODS: Twenty-five asthma cases with FAO and 22 COPD patients were enrolled. High-resolution computed tomography was used to measure the wall area (WA) and lumen area (LA) of the proximal airway at the apical segmental bronchus of the right upper lobe (RB1) adjusted by body surface area (BSA) and bronchial wall thickening (BWT r ) of the peripheral airways and extent of expiratory air trapping (AT exp ). Respiratory impedance included resistance at 5 Hz (R5) and 20 Hz (R20) and resonant frequency (Fres). Total lung capacity (TLC) and residual volume (RV) were measured. RESULTS: Asthma patients had smaller RB1-LA/BSA than COPD patients (10.5 ± 3.4 vs. 13.3 ± 5.0 mm2/m2, P = 0.037). R5(5.5 ± 2.0 vs. 3.4 ± 1.0 cmH2O/L/s, P = 0.02) and R20(4.2 ± 1.7 vs. 2.6 ± 0.7 cmH2O/L/s, P = 0.001) were higher in asthma cases. AT exp and BWT r were similar in both groups. Regression analysis in asthma showed that forced expiratory volume in one second (FEV1) and Fres were associated with RB1-WA/BSA (R2= 0.34, P = 0.005) and BWT r (0.5, 0.012), whereas RV/TLC was associated with AT exp (0.38, 0.001). CONCLUSIONS: Asthma patients with FAO had a smaller LA and higher resistance of the proximal airways than COPD patients. FEV1 and respiratory impedance correlated with airway morphology.

Peak inspiratory flow rate measurement by using In-Check DIAL for the different inhaler devices in elderly with obstructive airway diseases.

BACKGROUND: Inhaler device technique is a common cause of treatment failure in patients with asthma and chronic obstructive pulmonary disease. Dry powder inhaler (DPI) requires optimal peak inspiratory flow rate (PIFR) for drug delivery. Low PIFR generation is common in the elderly. Patient lung function and intrinsic inhaler resistance are factors for determining generated PIFR and drug delivery from DPI. OBJECTIVES: We aimed to identify the PIFR of the older (aged >60 years) and the younger (aged ≤60 years) patients with obstructive airway diseases for the different inhaler devices (Turbuhaler® and Accuhaler). PATIENTS AND METHODS: A cross-sectional study was conducted from January to December 2014. Patients with obstructive airway diseases were recruited. Spirometry was performed. PIFR was measured by using an In-Check DIAL device. Individual PIFR values for each inhaler device were obtained for three consecutive measurements and then averaged. RESULTS: A total of 139 patients diagnosed with obstructive lung diseases (asthma, n = 109; chronic obstructive pulmonary disease, n = 30) were recruited. Of these, 71 patients (51%) were >60 years. The PIFR generated by the patients who were ≤60 years for nonresistance mode was not different from that generated by those aged >60 years (115.0 ± 15.2 L/min vs 115.4 ± 13.3 L/min, p = 0.86). Regarding the DPI, PIFR generated from the older group was significantly lower than that generated from the younger group for Turbuhaler (72.5 ± 18.8 L/min vs 82.4 ± 21.1 L/min, p = 0.01), but the PIFR generated was not significantly different between the older and the younger groups for the Accuhaler (93.8 ± 22.9 L/min vs 99.4 ± 24.2 L/min, p = 0.86). The low peak expiratory flow rate and PIFR from spirometry were associated with the suboptimal PIFR measured by using In-Check DIAL. DISCUSSION: Optimal PIFR is critical for DPI use in the elderly; appropriate DPI selection is essential for management. In-Check DIAL may be useful for detecting inhaler device problem among the elderly. CONCLUSION: Lower PIFR generated from Turbuhaler was noted in patients with airway diseases who were older than 60 years, when compared to the younger patients.

Minimal Clinically Important Differences (MCIDs) of the Thai Version of the Leicester Cough Questionnaire for Subacute and Chronic Cough.

OBJECTIVES: To investigate the minimal clinically important differences (MCIDs) of the Thai version of the Leicester Cough Questionnaire (LCQ-T) in patients with subacute and chronic cough. METHODS: Patients with cough for 3 or more weeks were recruited from outpatient clinics. They self-completed the LCQ-T at an initial evaluation and repeated the LCQ-T with a Global Rating of Change scale at follow-up. For the anchor-based method, the MCID was defined as a change in the LCQ scores that corresponded to the smallest improvement in Global Rating of Change score (+2 to +3). For distribution-based methods, the MCIDs were estimated from the standard error of measurement and a half and one-third of the SD of the LCQ score changes from baseline to follow-up. RESULTS: A total of 107 patients were included. The causes of cough were postinfectious cough/bronchitis (35.5%), asthma (20.6%), rhinosinusitis (16.8%), bronchiectasis (17.8%), and chronic obstructive pulmonary disease (9.3%). The anchor-based method yielded MCIDs of 1.1, 0.4, 0.4, and 0.4 for the total, physical, psychological, and social domains, respectively. The distribution-based method using standard error qof measurement yielded MCIDs of 0.8, 0.3, 0.3, and 0.3, whereas those using a half SD yielded MCIDs of 2.0, 0.6, 0.8, and 0.8 and those using one-third SD yielded MCIDs of 1.4, 0.4, 0.5, and 0.5 for the total, physical, psychological, and social domains, respectively. CONCLUSIONS: The MCIDs of the LCQ-T for subacute and chronic cough are 1.1, 0.4, 0.4, and 0.4 for the total, physical, psychological, and social domains, respectively. These estimates should be useful in making meaningful interpretations of the changes in quality of life because of cough.

Massive hemothorax in a beta-thalassemic patient due to spontaneous rupture of extramedullary hematopoietic masses: diagnosis and successful treatment.

Intrathoracic extramedullary hematopoiesis is an unusual but well-described entity. The condition is typically found in patients who have chronic hemolytic anemias, especially thalassemia. We report a case of a 38-year-old man with underlying beta thalassemia/hemoglobin E who developed intrathoracic extramedullary hematopoiesis. The hematopoietic masses spontaneously ruptured, resulting in massive hemothorax. The condition was confirmed by video-assisted thoracoscopy and successfully treated with surgery, hydroxyurea, and radiation.

Risk factors for strongyloidiasis hyperinfection and clinical outcomes.

Strongyloidiasis, caused by Strongyloides stercoralis, consists of various clinical syndromes. Strongyloidiasis hyperinfection leads to morbidity and mortality particularly in immunocompromized patients. This study aimed to determine the risk factors for strongyloidiasis hyperinfection and clinical outcomes. The medical records for hospitalized patients infected with S. stercoralis at Ramathibodi Hospital during 1994-2005 were retrospectively reviewed. Risk factors for strongyloidiasis hyperinfection were determined. There were 123 episodes of strongyloidiasis in 111 patients. The mean age was 46.8 +/- 17.8 years; 61% were males. Of 123 episodes, 37 (30.1%) had strongyloidiasis hyperinfection; the others had chronic strongyloidiasis. All the patients with strongyloidiasis hyperinfection and 88.3% of those with chronic strongyloidiasis were immunocompromized (p = 0.032); 89.2% of the former and 55.8% of the latter had received corticosteroids (p < 0.001). There were no significant differences in the type of immunocompromized host and the corticosteroid dosage between the two groups (p > 0.05). The hyperinfection group had a lower mean serum protein (p = 0.026) and albumin (p = 0.027) but a higher frequency of sepsis (p = 0.029), asthma-like symptoms (p = 0.025), adult respiratory distress syndrome (p = 0.026), and a longer duration of treatment (p=0.004). By logistic regression, corticosteroids use was a risk factor for hyperinfection (OR = 6.5, 95% CI = 2.1-20.0, p = 0.001). Most of the patients were treated with albendazole or thiabendazole, with a cure rate of 76.9%, whereas other recent cases treated with ivermectin had an average cure rate of 83.3%. The overall mortality rate was 8.1%.

Thoracic manifestations of paradoxical immune reconstitution inflammatory syndrome during or after antituberculous therapy in HIV-negative patients.

Immune reconstitution inflammatory syndrome (IRIS) is a consequence of exaggerated and dysregulated host's inflammatory response to invading microorganism, leading to uncontrolled inflammatory reactions. IRIS associated with tuberculosis (TB) is well recognized among human immunodeficiency virus (HIV)-infected patients receiving highly active antiretroviral therapy, but it is less common among HIV-negative patients. IRIS can manifest as a paradoxical worsening or recurring of preexisting tuberculous lesions or development of new lesions despite successful antituberculous treatment. Hence, the condition might be misdiagnosed as superimposed infections, treatment failure, or relapse of TB. This pictorial essay reviewed diagnostic criteria and various thoracic manifestations of the paradoxical form of TB-associated IRIS (TB-IRIS) that might aid in early recognition of this clinical entity among HIV-negative patients. The treatment and outcomes of TB-IRIS were also discussed.