Short-term effects of air pollutant exposure on small airway dysfunction, spirometry, health-related quality of life, and inflammatory biomarkers in wildland firefighters: a pilot study.

Clinical Trials Registry: Study ID: TCTR20200828005.

Humoral and cellular immune responses against SARS-CoV-2 variants of concern induced by heterologous CoronaVac/ChAdOx-1 versus homologous ChAdOx-1 vaccination in the elderly.

BACKGROUND: The concept of heterologous vaccination against SARS-CoV-2 infection has been adopted in Thailand with limited data on the induction of humoral and cellular immunity, particularly the CoronaVac/ChAdOx-1 (CoVac/ChAd) regimen in the elderly. OBJECTIVE: In this study, the immune responses of the elderly induced by heterologous CoVac/ChAd and homologous ChAdOx-1 (ChAd/ChAd) vaccinations were demonstrated. METHODS: A prospective observational study involving healthy participants aged ≥ 60 years who received heterologous CoVac/ChAd or homologous ChAd/ChAd vaccination was conducted. Surrogate neutralizing antibody (NAb) and T-cell responses against the SARS-CoV-2 wild type (WT) and variants of concern were determined at pre and post vaccinations. RESULTS: At 4 and 12 weeks after heterologous or homologous vaccination, the NAb levels against WT, Alpha, Beta, and Delta variants between each group were not significantly different, except for significant lower NAb against the Beta variant in heterologous group at 12 weeks after vaccination. The NAb against the Omicron at 4 weeks post-vaccination were below the cutoff level for antibody detection in both groups. However, higher spike-specific CD4 T cell producing IFN-γ and TNF-α in the heterologous than the homologous vaccination were observed. Insignificant difference of cellular immune responses to spike-peptides of Alpha, Beta, and Delta variants and their WT homologues was demonstrated. CONCLUSIONS: In the elderly, heterologous CoVac/ChAd vaccination could induce NAb response against the WT and non-Omicron variants not different from the homologous ChAd/ChAd vaccination. Both regimens could not give adequate NAb of the Omicron strain. The heterologous vaccination, however, induced higher spike-specific Th1 cell response.

The roles of impulse oscillometry in detection of poorly controlled asthma in adults with normal spirometry.

BACKGROUND: Impulse oscillometry (IOS) has been introduced as a method of assessing asthma control. However, the cutoff IOS values for the detection of asthma control in adults are still unclear. OBJECTIVE: To assess the diagnostic ability of IOS for distinguishing between poorly controlled and well controlled adult asthmatic subjects with normal spirometry. METHODS: This cross-sectional study was conducted at the Lung Health Center, Chiang Mai, Thailand, between July 2019 and June 2020. IOS and spirometry were performed in all adult asthmatic subjects but only subjects with normal spirometry were enrolled. Poorly controlled asthma was defined in accordance with the Global Initiative for Asthma (GINA) plus an asthma control test (ACT) score ≤19. A Receiver Operating Characteristic (ROC) curve was plotted to detect poorly controlled asthma using the area under the ROC (AuROC) and 95%CI. RESULTS: One hundred and forty-two adult asthmatic subjects registering normal spirometry with a mean age of 53.4 ± 15.8 years were enrolled. Eighty-nine (62.7%) subjects were female. IOS parameters including heterogeneity of resistance at 5 Hz and resistance at 20 Hz (R5-R20) and area under reactance (AX) demonstrated excellent detection of poorly controlled asthma with an AuROC of 0.911 and 0.904, respectively. The z-score or absolute value of R5-R20 ≥ 0 and 1 cmH2O/L/s, respectively, represented the highest AuROC of 0.86, with a sensitivity and a specificity of ≥80.0% for the detection of poorly controlled asthma. CONCLUSION: IOS is a valuable tool for the detection of poorly controlled asthma in adults with normal spirometry.

Neutralizing antibody and T cell responses against SARS-CoV-2 variants of concern following ChAdOx-1 or BNT162b2 boosting in the elderly previously immunized with CoronaVac vaccine.

BACKGROUND: The existence of SARS-CoV-2 variants of concern (VOCs) in association with evidence of breakthrough infections despite vaccination resulted in the need for vaccine boosting. In elderly individuals, information on the immunogenicity of booster vaccinations is limited. In countries where the CoronaVac inactivated vaccine is the primary vaccine, the appropriate boosting regimen is not clear. Immunologic studies of the effects of booster vaccination against VOCs, particularly Delta and Omicron, following CoronaVac in elderly individuals are helpful for policy makers. In this study, we determined the immune responses against VOCs following ChAdOx-1 or BNT162b2 boosting in elderly individuals previously immunized with CoronaVac. RESULTS: Before boosting, the median % inhibition of neutralizing antibodies (NAbs) against the wild-type (WT), Alpha, Beta, Delta and Omicron variants in the ChAdOx-1 and BNT162b2 groups was 52.8% vs. 53.4, 36.6% vs. 39.9, 5.2% vs. 13.7, 34.3% vs. 44.9, and 20.8% vs. 18.8%, respectively. After boosting with ChAdOx-1 or BNT162b2, the % inhibition of NAbs were increased to 97.3% vs. 97.4, 94.3% vs. 97.3%, 79.9 vs. 93.7, 95.5% vs. 97.5, and 26.9% vs. 31.9% for WT, Alpha, Beta, Delta and Omicron variants, respectively. Boosting with BNT162b2 induced significantly higher NAb levels than boosting with ChAdOx-1 against the Alpha, Beta and Delta variants but not the WT and Omicron variants. NAb levels against Omicron variant were not significantly different before and after boosting with ChAdOx-1 or BNT162b2. To evaluate T-cell responses, S peptides of the WT, Alpha, Beta and Delta variants were used to stimulate T cells. Upon stimulation, the expression of IL-17A in CD8 T cells was higher in the BNT162b2 group than in the ChAdOx-1 boosting group. However, IFN-γ production in CD4 and CD8 T cells did not significantly differ under all vaccination regimens. The expression of FasL in CD4 T cells, but not CD8 T cells, was higher in the BNT162b2-boosted group. CONCLUSION: Boosting with either ChAdOx-1 or BNT162b2 in CoronaVac-primed healthy elderly individuals induced high NAb production against all examined VOCs except Omicron. BNT162b2 stimulated higher NAb and some T-cell responses than ChAdOx-1. Vaccine boosting is, therefore, recommended for elderly individuals previously immunized with CoronaVac.

Effects of exposure to glyphosate on oxidative stress, inflammation, and lung function in maize farmers, Northern Thailand.

BACKGROUND: Glyphosate is a herbicide which is commonly used in agricultural areas. However, previous studies on glyphosate exposure in farmers and their health are still scarce. METHODS: A longitudinal pre-post study was performed among maize farmers. Information from questionnaires, urine and blood samples, and lung function were collected a day before and a day after glyphosate application in the morning. The urine samples were analyzed using liquid chromatography-tandem mass spectrometry to detect glyphosate levels. Serum samples were analyzed to detect malondialdehyde (MDA), glutathione (GHS), and C-reactive protein (CRP) levels using thiobarbituric acid, dithiobisnitrobenzoic acid, and nephelometry, respectively. Lung function performances were measured using a spirometer. RESULTS: A total of 180 maize farmers met the study inclusion criteria. After glyphosate application, it was found that increased urinary glyphosate levels contributed to increased serum MDA (ß = 0.024, 95% CI = 0.000, 0.0047) and decreased serum GHS (ß = -0.022, 95% CI = -0.037, -0.007), FEV1 (ß = -0.134, 95% CI = -0.168, -0.100), FEV1/FVC (ß = -0.062, 95% CI = -0.082, -0.042) and PEF (ß = -0.952, 95% CI = -1.169, -0.735). CONCLUSIONS: Exposure to glyphosate during glyphosate application had significant effects on oxidative stress and lung function in maize farmers.

The comparative effect of Leukotriene receptor antagonist add on therapy and step up inhaled Corticosteroid in partially controlled asthma: An open-labeled randomized controlled trial.

BACKGROUND: No studies are comparing the impact of the add-on leukotriene-receptor antagonist (LTRA) with a step-up dose of inhaled corticosteroids (ICS) in partly controlled asthma patients with asthma control test (ACT) score ˂ 23. OBJECTIVE: To study the effect of LTRA add-on therapy in comparison to a step-up to medium dose of ICS in partially controlled asthma. METHODS: An open-labeled randomized controlled trial was conducted in asthma subjects with partly controlled asthma who had been in regular receipt of low dose ICS. All subjects were assessed for asthma using ACT, daytime and nighttime symptoms, rate of relievers used, spirometry, and impulse oscillometry (IOS) at 3 and 6 months. Subjects were randomized to receive daily oral LTRA 10 mg or step-up medium dose of ICS. RESULTS: Between June 2020 and January 2021, 50 participants were enrolled, all patients completing the study. After treatment, mean ACT scores were increased to more than 23 indicating well-controlled asthma in both groups, control being sustained throughout the whole 6-month study period (P ˂ 0.001). Within each group, ACT scores were improved by a minimal clinical important difference (MCID) ≥ 3 points at 6 months, compared to baseline values. There were significant decreases in nighttime and daytime symptoms, and the numbers of rescue relievers used in 4 weeks in both groups compared to baseline (P ˂ 0.001). CONCLUSIONS: LTRA add-on therapy in partially controlled asthma patients is comparable with step-up to medium dose of ICS/LABA as regards asthma control.

Bradycardia and Heart Rate Fluctuation Are Associated with a Prolonged Intensive Care Unit Stay in Patients with Severe COVID-19.

Background and Objective: Bradycardia has been observed among patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is suspected to be associated with poorer outcomes. Heart rate (HR) fluctuation has been found to be correlated with a greater mortality rate in critically ill patients. The association of bradycardia and HR fluctuation with the outcome of severe coronavirus disease 2019 (COVID-19) patients has not been clarified. Therefore, we aimed to examine whether bradycardia and HR fluctuation correlated with poor outcomes in patients with severe COVID-19. Materials and Methods: We conducted a secondary analysis from a prospective data collection of patients admitted to the intensive care unit, between April and June 2021, at Chiang Mai University Hospital. Results: The results showed that 62 of 86 patients (72.1%) had bradycardia, defined by HR < 60 beats per minute (bpm). The number of patients with high HR fluctuation, defined as the difference in HR during admission ≥ 40 bpm, was greater among the bradycardia group than in the non-bradycardia group (70.9% vs. 14.7%, p = 0.015, respectively). The patients with bradycardia had greater levels of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). In addition, a greater proportion of patients with bradycardia received interleukin-6 inhibitors and hemoperfusion as a rescue therapy than those with non-bradycardia. After adjusting for age, gender, body mass index, CRP, and mechanical ventilator; bradycardia and the high HR fluctuation were significantly associated with a longer length of stay in the intensive care unit (ICU-LOS), with adjusted risk ratios of 2.67, 95% CI; 1.02, 6.94, p = 0.045 and 2.88, 95% CI; 1.22, 6.78, p = 0.016, respectively. Conclusion: We found that bradycardia and a high heart rate fluctuation were associated with a poorer ICU outcome in terms of longer ICU-LOS among the patients with severe COVID-19.

Comparative Study of Early Impacts of Post-COVID-19 Pneumonia on Clinical Manifestations, Pulmonary Function, and Chest Radiographs.

Background and Objectives: Scant data regarding early post-COVID-19 effects are available, especially in younger people. Therefore, the objective of this study was to explore the early clinical impacts of post-COVID-19 pneumonia, comparing severe and non-severe patients. Materials and Methods: A cross-sectional study was conducted in adult patients admitted with COVID-19 pneumonia from April to May 2021. Demographic data, symptoms and signs, quality of life, Hospital Anxiety and Depression Scale (HADS), chest radiograph (CXR), pulmonary function tests (spirometry, impulse oscillometry), fractional exhaled nitric oxide (FeNO), and exercise capacity were assessed one month after hospital discharge. Twenty-five healthy control subjects that were age- and gender-matched were recruited for comparisons. Results: One hundred and five patients, with a mean age of 35.6 ± 15.8 years and 54 (51.4%) males, participated and were categorized into the non-severe pneumonia (N = 68) and severe pneumonia groups (N = 37). At a one-month follow-up visit (the time from the onset of the disease symptoms = 45.4 ± 5.9 days), the severe group had more cough, fatigue, and skin rash with higher dyspnea scale, more residual CXR lesions, and lower quality of life scores. Forced vital capacity (FVC) was lower in the severe group (88.3% of predicted value) and non-severe group (94.6% of predicted value) than in the healthy controls (p = 0.001). The six-minute walk distance was significantly lower in the non-severe group, at 79.2 m, and in the severe group, at 103.8 m, than in the healthy control subjects (p < 0.001). Conclusions: Adult patients with COVID-19, especially those with clinically severe pneumonia, still had residual symptoms and chest radiographic abnormalities, together with poorer quality of life and lower exercise capacity, one month after hospital discharge.

The short-term associations of particular matters on non-accidental mortality and causes of death in Chiang Mai, Thailand: a time series analysis study between 2016-2018.

Open burnings, agricultural and forest fires, are the major sources of particulate matters (PM) in Chiang Mai during dry season. We aim to determine the association of an increased daily PM (PM10, PM2.5) and daily non-accidental mortality and causes of death in Chiang Mai. The association between PM and daily non-accidental mortality including causes of death were analyzed using a generalized linear model with Poisson distribution. The results showed that PM10 and PM2.5 were associated with daily non-accidental mortality on different lag days (adjusted RR range from 1.009-1.018 and 1.016 for each 10 µg/m3 increment of PM10 and PM2.5, respectively). The causes of death associated with PM10, PM2.5 found on different lag days were chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and sepsis. We concluded that PM10 and PM2.5 are associated with daily non-accidental mortality and causes of death were COPD, CAD, and sepsis.

The validity and reliability of the Thai version of the asthma control test.

BACKGROUND: The Asthma Control Test (ACT) has been widely used for the assessment of asthma control. However, it has never been validated in adult Thai asthmatic patients. OBJECTIVE: To determine the validity and reliability of the Thai version of the ACT in adult Thai asthmatic patients. METHODS: Any correlation between ACT and level of asthma controlled was determined using the Spearman's rank correlation coefficient. The ACT was carried out at 2 visits to a physician (4-12 weeks apart) to ascertain the level of reliability. Discriminant validity was determined using an area under receiver operating characteristic curve (AuROC) to identify the optimum cut-off point of the levels of control. RESULTS: Seventy-one asthmatic adult patients, 40 (56.3%) female with a mean age of 54.2 ± 14.7 years were enrolled. The Thai version of ACT showed an acceptable internal consistency reliability with a Cronbach's alpha = 0.75. Test-retest reliability was 0.82. There was a significant correlation between the ACT scores and GINA symptom control tool (r = 0.87, p < 0.001). An ACT ≤ 22 was used to screen "not well-controlled" asthma with a sensitivity of 96.4% and specificity of 93.0% and an ACT score ≤ 19 was used to screen "uncontrolled" asthma. CONCLUSIONS: The Thai version of ACT is valid and a reliable tool for use in adult Thai asthmatic patients. However, the cut off points of ACT for levels of control should be changed to 22 and 19 for differentiation between well vs. partly controlled and partly vs. uncontrolled asthma, respectively.

Real-world observational study of the evaluation of inhaler techniques in asthma patients.

BACKGROUND: Inhaler devices are a keystone in the management of asthma during the maintenance phase of treatment. OBJECTIVE: To evaluate techniques for using inhaler devices in asthma patients. METHODS: A prospective cross-sectional study was conducted to assess patient compliance with correct techniques for using inhaler devices across three regimens: pressurized metered-dose inhaler (pMDI), Accuhaler®, and Turbuhaler®. The compliance of patients with essential steps for correct device usage in the case of each regimen was recorded. These were recorded when patients presented for a routine visit and one month after receiving face-to-face training. The percentage of compliance between the use of the devices and the risk factors related to incorrect techniques were analyzed by logistic regression analysis. The percentages of incorrect techniques were compared between the two visits using a Chi-squared test. RESULTS: A total of 108 asthma patients (35.2% male), with a mean age of 57.5 ± 12.3 years were evaluated. Percentages of incorrect use of Accuhaler®, pMDI, and Turbuhaler® were 50%, 48%, and 55.6%, respectively. The most common incorrectness's is breath out gently to residual volume (approximately one-third). Previous treatment by a pulmonologist for less than 2 years was the single factor related to incorrect technique [Adjusted OR = 2.8 (95%CI, 1.2-6.3), p = 0.02]. Formal training resulted in a statistically significant decrease in percentage of incorrect techniques (52.8% vs. 32.1%, p = 0.02). CONCLUSIONS: Inhalation technique in asthma patients was mostly unsatisfactory, especially in patients who had been treated by a pulmonologist for less than 2 years. Face-to-face training significantly improved good technique in all devices.

A Real-World Effectiveness of Subcutaneous Immunotherapy on the Cost of Medication, Allergic Rhinitis, and Asthma Exacerbations, as well as Upper Respiratory Tract Infection in Subjects with Allergic Rhinitis with or without Asthma: A Retrospective Pilot Study.

Background and Objectives: Real-world studies are limited regarding the effectiveness of SCIT on allergic rhinitis (AR) with and without asthma and the cost of medication in Thailand. Moreover, limited data exist regarding the effectiveness of SCIT on worldwide upper respiratory tract infection (URTI). Therefore, the objective of this study was to compare the medication costs, rate of AR and asthma exacerbations, and rate of URTI in AR with or without asthma subjects before and during three years after receiving the maintenance phase of SCIT, compared with a standard usual care (SUC) group. Materials and Methods: A real-world retrospective study was conducted in AR subjects with or without asthma. From January 2001 to December 2018, 24 subjects with or without asthma received SCIT added to SUC, and 16 subjects were treated with SUC only at the Allergy and Chest Clinic of Chiang Mai Ram Hospital, Chiang Mai, Thailand. The cost of medication was recorded. AR and asthma exacerbations and URTI events were also collected. Results: From between-group comparisons, the cost of medication (THB) in the SCIT group at the one-, two-, and three-year follow up was significantly lower (587.4 (348.3-1374.6) vs. 1562.4 (1315.1-1857.3), p < 0.001, 501.2 (302.9-839.0) vs. 1728.3 (1190.0-2236.1), p < 0.001, and 372.4 (284.8-752.4) vs. 1500.3 (1217.9-1748.9), p < 0.001, respectively)), and AR and asthma exacerbations were significantly reduced at the three-year follow-up. From within-group comparisons, the cost of medication (THB) and AR and asthma exacerbations were significantly lower in the SCIT group at the one-, two-, and three-year follow-up. The URTI event was significantly reduced in the SCIT group at the two- and three-year follow-up. Conclusions: SCIT in subjects with AR with or without asthma was associated with a significantly reduced cost of medication, rates of AR and asthma exacerbations, and URTI events in the long term.

Diagnostic Ability of Impulse Oscillometry in Diagnosis of Chronic Obstructive Pulmonary Disease.

The diagnosis of chronic obstructive pulmonary disease (COPD) mainly relies on spirometry. Due to the complexity of spirometry, easier-to-do impulse oscillometry (IOS) has been introduced as a complementary approach to conventional pulmonary function testing. Therefore, this study aimed to assess the efficacy of the diagnostic ability of IOS for diagnosing chronic obstructive pulmonary disease (COPD). This cross-sectional study was conducted at the Lung Health Center, Chiang Mai University, Thailand, between June 2019 and January 2020. IOS and spirometry were performed with all subjects suspected of having COPD. A Receiver Operating Characteristic (ROC) curve was plotted, the area under the ROC (AuROC) and 95%CI were compared among COPD and chronic smokers. One hundred and seventeen subjects suspected of having COPD with a mean age of 68.6 ± 8.6 years old were enrolled. Of these 103 (88.0%) were male. Thirty healthy subjects were also enrolled. IOS parameters including resistance at 5 Hz (R5), resonant frequency (Fres), area under reactance (AX), heterogeneity of resistance (R5-R20), and reactance at 5 Hz (X5) demonstrated excellent overall accuracy relative to the diagnosis of COPD with an AuROC ranging from 0.80 - 0.84. The AX ≥ 8.66 cmH2O/L represented an AuROC = 0.79, with a sensitivity of 79.1% and a specificity of 78.0% for the diagnosis of COPD. IOS is a valuable tool for use in the diagnosis of COPD. It may be used in subjects who cannot carry out the spirometric procedure.

Validity and Reliability of a Thai Version of Family Satisfaction with Care in the Intensive Care Unit Survey.

PURPOSE: To examine reliability and validity of a Thai version of the Family Satisfaction with Intensive Care Unit (FS-ICU 24) questionnaire and use this survey in intensive care units (ICUs) in Thailand. MATERIALS AND METHODS: The standard English FS-ICU questionnaire was translated into the Thai language using translation and culture adaptation guidelines. After reliability and validity testing, we consecutively surveyed the satisfaction of family members of ICU patients over 1 year. Adult family members of patients admitted to medical or surgical ICUs for 48 hours or more who had visited the patients at least once during the ICU stay were included. RESULTS: In all, 315 (95%) of 332 surveys were returned from family members. Cronbach's α of the Thai FS-ICU 24 questionnaire was 0.95. Factor analysis demonstrated good construct validity. The mean (±SD) of total satisfaction score, overall ICU care subscale, and decision-making subscale were 81.5 ± 14.3, 81.0 ± 15.6, and 82.0 ± 14.0. Items with the lowest scores were the waiting room atmosphere and the frequency of doctors communicating with family members about the patient's condition. The mean total satisfaction score tended to be higher in family members of survivors than in family members of nonsurvivors (81.9 ± 13.8 vs 77.7 ± 16.2, p value = 0.059). The overall satisfaction scores between medial ICU and surgical ICU were not significantly different. CONCLUSION: The Thai version of FS-ICU questionnaire was found to have acceptable reliability and validity in a Thai population and can be used to drive improvements in ICU care. TRIAL REGISTRATION: www.clinicaltrials.in.th, TCR20160603002. HOW TO CITE THIS ARTICLE: Tajarernmuang P, Chittawatanarat K, Dodek P, Heyland DK, Chanayat P, Inchai J, et al. Validity and Reliability of a Thai Version of Family Satisfaction with Care in the Intensive Care Unit Survey. Indian J Crit Care Med 2020;24(10):946-954.

Effect of the Application of the Global Lung Initiative 2012 Spirometry Reference Equation on the Diagnosing and Classifying Degree of Airway Obstruction in Thai Adults Aged 40 to 80 Years Old.

Background and objective: Changing to a different spirometry reference equation can result in misinterpretation of spirometric findings. Currently, there is limited data about any discordance between the interpretations of airway obstruction (AO) using the Global Lungs Initiative (GLI) 2012 and the currently employed Thai reference equations (Siriraj) in Thai adults. Therefore, this study aimed to determine differences in diagnosis around AO and classification of the severity of AO using the GLI2012 and Siriraj reference equations in Thai adults. Materials and Methods: We analyzed spirometric results from Thai adults aged 40-80 years old (n = 2084), which were collected at the Lung Health Center, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand between January 2005 and December 2015. The diagnoses concerning the AO were interpreted using the GLI2012 and Siriraj reference equations. The severity of AO in each case was classified into five grades, including mild, moderate, moderately severe, severe, or very severe. McNemar's test was used to analyze differences in diagnosis of AO and classification of the level of severity. The Kappa statistic was used to determine agreements of diagnosis of AO and classification of severity between the two reference equations. Results: There were significant differences in both diagnosis of AO and their classifying severity level between the two reference equations (p-value < 0.001). However, the levels of agreement between the two reference equations were moderate to very good in different age and sex groups (Kappa values ranged from 0.62 to 0.78 for the diagnosis of AO and 0.54 to 0.89 for the classification of severity). Conclusions: Changing from the Siriraj to the GLI2012 reference equations underestimates the proportion of airway obstruction in Thai adults.

Exercise Performance as a Predictor for Balance Impairment in COPD Patients.

Background and objective: Six-minute walk test (6-MWT) is a widely used test for assessing exercise performance in chronic obstructive pulmonary (COPD). However, the association between reduced walking distance and balance impairment in COPD has not been directly investigated. Therefore, the aim of this study was to identify exercise performance as a predictor for balance impairment in COPD. Materials and Methods: The cross-sectional study was conducted at a single visit involving stable COPD patients in Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand from November 2015 to October 2017. The 6-MWT was measured for in all subjects. The prognostic confounding factors were also collected for all subjects. Balance test was measured using the Berg Balance Scale (BBS) and the Timed Up and Go (TUG) test. A cut-off score of BBS < 46 and/or the TUG ≥ 13.5 s was classified as balance impairment. Multivariable logistic regressions were performed to identify the six-minute walk distance (6-MWD) as a predictor for balance impairment in COPD. Results: Of the 176 COPD subjects assessed for eligibility, 118 COPD patients were enrolled including 86 males (72.9%) with a mean age of 73.5 ± 8.1 years. Thirty-three (28.0%) cases were classified with a balance impairment. The 6-MWD < 300 m was the predictor of balance impairment in COPD with an adjusted risk ratio of 10.10 (95%CI; 2.87, 35.61, p-value < 0.001). Conclusions: The 6-MWT is not only useful for evaluation of exercise performance, but also for prediction of balance impairment in patients with COPD. Our study suggests that the 6-MWD < 300 m is an important risk factor for balance impairment in COPD.

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.

Risk Factors of Severe Acute Exacerbation of Chronic Obstructive Pulmonary Disease Among Patients Regularly Managed by Pulmonologists.

Objective: The present study intended to determine the risk factors of severe exacerbation in chronic obstructive pulmonary disease patients even though managed by pulmonologists on a regular basis. Material and Method: A retrospective case-controlled study was conducted at the chest clinic, Maharaj Nakorn Chiang Mai Hospital from 1st August 2009 to 31st July 2010. The clinical relevant data for acute exacerbation (age, sex, co-morbidity, severity of COPD, COPD medication, annual influenza vaccination, compliance with inhaled drug use, chest radiographic abnormality, and long-term oxygen therapy) were compared between severe AECOPD and stable COPD patients by logistic regression analysis. Results: Out of 137 COPD patients, 17 (12.4%) had severe AECOPD with 29 episodes (21.2%). Six risk factors were identified, two modifiable and four non-modifiable. The two modifiable risk factors were annual influenza non-vaccination (odds ratio [OR] 27.79; 95% confidence interval [CI], 2.29-337.66, p-value = 0.01) and improper use of inhaled devices (OR 9.94, 95%CI 1.07-92.54, p-value = 0.04). The four non-modifiable risk factors were age <60 yrs (OR, 10.67; 95%CI, 1.92-59.31, p-value = 0.01), hypertension (OR, 4.03; 95%CI. 1.05-15.44, p-value = 0.04), enlarged pulmonary trunk as demonstrated by chest radiograph (OR, 8.61; 95%CI, 1.49-49.85, p-value = 0.02), and long-term oxygen therapy (OR, 7.09; 95%CI, 1.36-37.00, p-value = 0.02). Conclusion: Six risk factors of severe AECOPD among patients whom were provided regularly managed by pulmonologists were identified; two of them, annual influenza non-vaccination and improper use of inhaled devices, could be potentially modified.

Effects of seasonal smog on asthma and COPD exacerbations requiring emergency visits in Chiang Mai, Thailand.

BACKGROUND: Seasonal smog produces particulate matters that are less than 10 microns in diameter (PM10), which are known to have several impacts on the respiratory system. OBJECTIVE: This study was to determine the association of an increased PM10 level due to seasonal smog in Chiang Mai and emergency visits for asthma and chronic obstructive pulmonary disease (COPD) exacerbations. METHOD: A retrospective cross-sectional study was conducted between the months of January and March from 2006 until 2009. The association of an increased PM10 level and the daily number of asthma and COPD exacerbations were analyzed using a generalized linear model; a Poisson regression model was fit to the number of daily emergency visits using predictor variables: lags of PM10, day of the week, and time. RESULTS: There were a total of 917 emergency visits for acute exacerbations of asthma and COPD, with a median of 2 visits per day (range 0-10). The median PM10 level during the same interval was 64.5 microgram per cubic meter (µg/m3) (16-304). For every 10 µg/m3 rise in PM10 concentration, there was a lag time of 6 days for asthma exacerbations [Adjusted relative risk (RR)=1.020; 95% confident interval (CI), 1.001-1.040; (p=0.014)], 7 days for COPD exacerbations [RR=1.030; 95%CI, 1.010-1.050 (p=0.024)] and 7 days for all exacerbations [RR=1.030 95%CI, 1.010-1.040 (p<0.001)]. CONCLUSIONS: This study confirms the effect of increasing PM10 concentrations from seasonal smog on asthma and COPD exacerbations. However, there was an approximately 1 week lag time between the elevated PM10 levels and time to emergency visits due to disease exacerbation.

Quality Assurance of Spirometry for COPD Clinic Accreditation in Thailand.

Objective: To evaluate quality of spirometry for COPD clinic accreditation. Material and Method: A minimum of 25 spirograms from each of 38 hospitals were evaluated using the American Thoracic Society (ATS)/European Respiratory Society (ERS) acceptability criteria. Technicians were separated into two groups based on their respective level in spirometry training, previously trained-certified, and naïve (not formally trained-certified) groups. Unpaired t-test and Chi-square were used to compare differences between the two groups. Statistical significance was set at p<0.05. Results: Thirty-eight technicians from 38 clinics submitted a total of 1,556 spirograms for accreditation evaluation. Of those, 1,066 (68.5%) spirograms met all ATS/ERS acceptability criteria. Only 47.4% of the clinics received an A grade. All clinics that received an A grade were staffed by trained-certified technicians. Significantly, more spirograms failed to meet the criteria from clinics with naïve technicians than clinics with trained-certified technicians (18.2% vs. 80.8%, p-value <0.001). Criteria where the trained-certified group significantly achieved than naive group were satisfactory exhalation (93.4% vs. 20.9%, p-value <0.001), no early termination (98.5% vs. 58.6%, p-value <0.001), maximal effort throughout (96.2% vs. 89.1%, p-value <0.001), and good start (91.6% vs. 79.9%, p-value <0.001). Conclusion: Spirometry performed by the Thoracic Society of Thailand trained-certified technician was distinguishably higher quality than by a naïve technician. Our results are a reminder of the importance of quality assurance for spirometry in clinical practice.