Satisfaction and tolerability using virtual reality (VR) as adjunctive treatment during flexible bronchoscopy: a randomized control trial.

BACKGROUND: Patient comfort during invasive and therapeutic procedures is important. The use of virtual reality (VR) devices during flexible bronchoscopy (FB) as a method of distraction to increase patient tolerability and improve satisfaction has not been investigated. We aim to assess the satisfaction and tolerability of participants undergoing FB with or without VR. METHODS: This was a single-center, open-label study on patients undergoing bronchoscopy, randomized into the control and interventional (VR) groups. The control group received standard care during FB. The interventional group was given a VR device during FB showing nature videos with soothing instrumental music. Pain, breathlessness, and cough were evaluated using a 10 cm visual analogue scale administered before and after FB. Anxiety was assessed using the State-Trait Anxiety Inventory. Satisfaction questionnaire (5-point Likert scale) was given to participants post FB. RESULTS: Eighty participants enrolled, 40 in each arm. Median (IQR) satisfaction score in the VR group was 5.0 (3.0-5.0), and in the control group was 4.0 (3.0-5.0); (p < 0.001). Breathlessness, cough, and anxiety post FB were significantly less severe in the interventional group (p = 0.042, p = 0.001, p < 0.001), but the pain was not significantly different (p = 0.290). CONCLUSION: VR used during FB led to better participants' satisfaction and tolerability (breathlessness and cough). There was a significantly lower anxiety score in the VR group.

Meigs syndrome presenting with recurrent unilateral pleural effusion.

Pelvic tumours are a rare cause of pleural effusion. We describe an approach to a case of Meigs syndrome with recurrent unilateral pleural effusion. A woman in her 60s' presented with recurrent right-sided pleural effusion, leading to cough and shortness of breath. Thoracentesis yielded exudative pleural fluid with cytology negative for malignancy. Pleuroscopy revealed inflamed pleura, and pleural biopsy was consistent with inflammatory changes. The patient's cancer antigen 125 level was elevated at 256 U/mL. Given the high suspicion of malignancy, a computed tomography scan of the chest, abdomen, and pelvis was performed and revealed ascites and a large left ovarian and uterine mass. The patient underwent a total abdominal hysterectomy and bilateral salphingo oophorectomy after experiencing three additional episodes of pleural effusion. Histological examination revealed the left ovarian mass to be a cellular fibroma and the uterine masses to be leiomyomata. Following the operation, there was no recurrence of pleural effusion.

APPaRENT 3: Asthma Patients' and Physicians' Perspectives on the Burden and Management of Asthma in Seven Countries.

INTRODUCTION: Asthma management is strongly dependent on physician and patient beliefs and perceptions about the disease and its long-term treatment. The APPaRENT 3 study was conducted to explore factors influencing treatment choice and to understand patients' and physicians' attitudes and perspectives on the use of controller inhalers in regular versus flexible dosing for asthma management. METHODS: This cross-sectional survey of patients with asthma and treating physicians was conducted in seven countries: Indonesia, Malaysia, Philippines, Thailand, Vietnam (patient survey only), Saudi Arabia, and the United Arab Emirates. Assessment was carried out through an online/face-to-face questionnaire, where patients' viewpoints were focused on their attitudes and beliefs about asthma and treatment adherence, whereas physicians' viewpoints were gathered on their attitudes and beliefs about asthma management, knowledge of and adherence to asthma treatment guidelines, and asthma treatment regimens. RESULTS: Overall, 1400 patients (mean age, 34 years) and 599 physicians (mean age, 43 years) were included in the survey. Physicians similarly prioritised symptom control (39%) and exacerbation reduction (40%) in moderate asthma, whereas patients prioritised symptom control (41%) over exacerbation reduction (22%). Although both groups (physicians, 86%; patients, 84%) perceived asthma as well-controlled, poor management was evident based on Asthma Control Test (ACT) scores (mean, 15.7; standard deviation, 4.14; 82% had an ACT score < 20) and high symptom burden (39% reported nighttime awakenings or early mornings ≥ 2 nights/week). Most patients (76%) with moderate asthma were prescribed regular dosing, with the most common treatment being inhaled corticosteroid (ICS)/long-acting ß2-agonist (LABA) with as-needed inhaled short-acting ß2-agonist (SABA; 20%). Among patients on maintenance and reliever therapy, 93% of patients received a separate inhaled reliever. CONCLUSIONS: Despite high symptom burden, patients overestimated their level of asthma control. Physicians prioritised controlling symptoms and reducing exacerbations as treatment goals for moderate asthma, often prescribing regular dosing with ICS/LABA with as-needed inhaled SABA.

Managing asthma depends a lot on what doctors and patients think about the illness and its long-term treatment. This study looked into what influences treatment decisions and what patients and doctors think about using inhalers regularly or on an as-needed basis to manage asthma across seven countries (Indonesia, Malaysia, Philippines, Thailand, Vietnam [patient survey only], Saudi Arabia, and the United Arab Emirates). In this study, patients with asthma and doctors managing asthma completed an online/face-to-face questionnaire. The study aimed to understand what patients think about asthma and their treatment plan. Meanwhile, the doctors were asked what they think about managing asthma and how much they apply clinical guidelines for treating patients with asthma. Doctors believed it is equally important to control symptoms and prevent worsening of symptoms in patients with moderate asthma, while patients cared more about controlling symptoms than preventing worsening of symptoms. While doctors and patients both regarded asthma as well-controlled, many patients had low Asthma Control Test scores and experienced a lot of symptoms, suggesting that they are poor perceivers of asthma control. Most patients with moderate asthma were given regular treatment, usually with inhaled corticosteroid combined with long-acting ß₂-agonist along with as-needed short-acting ß₂-agonist as a reliever. Most patients who were prescribed the same inhaler for regular use and as a reliever also had a separate inhaler for quick relief of symptoms. This study shows the need for patients and doctors to have better conversations about asthma, its treatments, and what to expect from them.

Evaluation of short-acting Beta-2-agonist prescriptions and associated clinical outcomes: Findings from the SABA use IN Asthma (SABINA) study in Asia.

Background: The extent of short-acting Beta-2-agonist (ß2-agonist) (SABA) use across Asian countries is not well documented. As part of the SABA use IN Asthma (SABINA) III study, we assessed SABA prescriptions and clinical outcomes in patients with asthma from Asia. Methods: This cross-sectional study recruited patients (aged ≥12 years) with asthma from 8 Asian countries. Data on disease characteristics and asthma treatments were collected using electronic case report forms. Patients were classified by practice type (primary or specialist care) and investigator-defined asthma severity (per Global Initiative for Asthma [GINA] 2017 recommendations). The association of SABA prescriptions with clinical outcomes was analyzed using multivariable regression models. Results: Overall, 3066 patients were analyzed, with a mean (standard deviation) age of 51.8 (16.7) years; of these patients, 2116 (69%) were female, 2517 (82.1%) had moderate-to-severe asthma and 2498 (81.5%) and 559 (18.2%) were treated in specialist and primary care, respectively. In total, 1423 (46.4%) patients had partly controlled/uncontrolled asthma, with 1149 (37.5%) patients experiencing ≥1 severe asthma exacerbation in the previous year. Overall, 800 (26.7%) patients were prescribed ≥3 SABA canisters in the previous year, which is regarded as overprescription and was associated with a significantly decreased odds of at least partly controlled asthma and increased incidence rates of severe exacerbations (P < 0.01 for both associations). Conclusion: The findings from this cohort of predominantly specialist-treated patients with asthma indicate SABA overprescription in at least 1 in every 4 patients, and this overprescription is associated with poor clinical outcomes. These data highlight the need for adherence to recently updated asthma treatment recommendations in Asia.

A rare presentation of isolated carpal bone tuberculous osteomyelitis mimicking gouty arthritis.

Tuberculosis (TB) is the most prevalent infectious disease in Southeast Asia. It causes both pulmonary and extrapulmonary diseases. TB of the wrist is rare and presents as osteomyelitis or tenosynovitis. We report a middle-aged male with carpal bone tuberculous osteomyelitis. He presented with left wrist pain initially treated as gouty arthritis. Within 2 weeks, he developed seropurulent discharge with osteomyelitic changes on imaging. He underwent debridement, and intraoperatively, there was destruction of most carpal bones. Histopathological examination revealed chronic granulomatous inflammation with abscess formation. Anti-TB medication was initiated, and he made a complete recovery with almost full range of wrist movement after 9 months of treatment. This case serves as a reminder that TB is a great mimicker, and a high index of suspicion is required to make a diagnosis of TB of the wrist. Early initiation of anti-TB is pivotal to prevent complications and deterioration of joint functions.

Silicone pneumonitis after gluteal filler: a case report and literature review.

Liquid silicone (polydimethylsiloxane) is an inert material that is commonly used for cosmetic purpose. Silicone embolization syndrome (SES) can rapidly progress to pneumonitis as a consequence of the injection of nonmedical-grade liquid silicone. We describe a case of severe silicone pneumonitis complicated with acute respiratory distress syndrome and bilateral pneumothorax secondary to silicone gluteal augmentation. In this case report, we aim to discuss our experience and approach in managing an uncommon case of SES.

Cluster Analysis Evaluating PM2.5, Occupation Risk and Mode of Transportation as Surrogates for Air-pollution and the Impact on Lung Cancer Diagnosis and 1-Year Mortality.

Objective: Epidemiological studies have reported the close relationship between risk for lung cancers and air pollution in particular, for non-smoking related lung cancers. However, most studies used residential address as proxies which may not estimate accurately an individual's air pollution exposure. Therefore, the aim of this study was to identify risk factors such as occupation and mode of transportation associated with lung cancer diagnosis and death. Methods: Subjects with lung cancer (n=514) were evaluated both by chart reviews for clinical data and interviews to determine residential address for ten years, main occupation and main mode of transportation. Annual particulate matter with diameter size less than 2.5 micrometre (PM2.5) concentration were calculated based on particulate matter with diameter size less than 10 micrometre (PM10) data recorded by Malaysian Department of Environment. Logistic regression analysis, cluster analysis and the Cox regression analysis were performed to the studied variables. Results: This study concurred with previous studies that lung adenocarcinoma were diagnosed in predominantly younger, female non-smokers compared to the other types of lung cancers. Lung adenocarcinoma subjects had annual PM2.5 that was almost twice higher than squamous cell carcinoma, small cell carcinoma and other histological subtypes (p=0.024). Independent of smoking, the κ -means cluster analysis revealed two clusters in which the high risk cluster involves occupation risk with air pollution of more than four hours per day, main transportation involving motorcycle and trucks and mean annual PM2.5 concentration of more than 30 based on residential address for more than ten years. The increased risk for the high-risk cluster was more than five times for the diagnosis of lung adenocarcinoma (OR=5.69, 95% CI=3.14-7.21, p<0.001). The hazard ratio for the high-risk cluster was 3.89 (95% CI=2.12-4.56, p=0.02) for lung adenocarcinoma mortality at 1 year. Conclusion: High-risk cluster including PM2.5, occupation risk and mode of transportation as surrogates for air-pollution exposure was identified and highly associated with lung adenocarcinoma diagnosis and 1-year mortality.

Suture Granuloma 14 Years Following Partial Thyroidectomy Masquerading as Tuberculosis af The Sinus Tract.

Suture granuloma rarely occurs after thyroid surgery using non-absorbable sutures. We report the case of a 63-year-old female with a chronic discharging sinus in the anterior neck region. She had a history of subtotal thyroidectomy at the age of 45. The sinus had been excised and was reported as granulomatous lesions suggestive of tuberculosis. She was treated with anti-tuberculous medications, but unfortunately, she developed side effects. Histopathological slides were re-evaluated, which showed evidence of foreign material under polarized light; hence, the diagnosis was revised to suture granuloma. In conclusion, although sinus tract discharges are commonly attributed to tuberculosis, physicians should consider suture granuloma if they encounter a patient who has undergone a surgical procedure in the past.

Disseminated tuberculosis masquerading primary myelodysplastic syndrome.

Tuberculosis is notoriously known to be a great mimicker of other diseases and may cause various haematologic abnormalities, especially with marrow involvement. A 61-year-old man who presented with right empyema and pancytopenia was diagnosed to have disseminated tuberculosis supported by the presence of caseating granuloma with Langhan's giant cells in the marrow and demonstration of acid-fast bacilli in the pleural fluid. Trilineage dysplasia from marrow aspirate was initially attributed to be reactive to the infection. A cytogenetic study was repeated after he showed poor response to a year of anti-tuberculosis treatment. The underlying primary myelodysplastic syndrome was unmasked when his cytogenetics showed trisomy 8. This case report has demonstrated the various haematological manifestations of tuberculosis and highlighted the importance of cytogenetic study in differentiating between primary and secondary myelodysplastic marrow changes.