Risk Factors Of Idiopathic Pulmonary Fibrosis In Pakistani Population: A Matched Case-Control Studyy.

OBJECTIVE: To evaluate the factors associated with idiopathic pulmonary fibrosisrisk. Methods: The case-controlstudywas conductedfromJanuary 5, 2017,toSeptember 4, 2018, attheprivate-sectorAga Khan University Hospital and the public-sector Jinnah Postgraduate Medical Centre, two large tertiary care centres in Karachi, andcomprisedadultpatientsof eithergenderwithdiagnosedidiopathicpulmonary fibrosis, asdefinedby the IndianChest Registry. Subjects without idiopathic pulmonary fibrosis but registered with the department of pulmonology of the two hospitalswere enrolledas controls.Datawas collectedusinga structuredquestionnaire, andanthropometricmeasurements were noted for each subject. Gastroesophageal reflux disease was assessed using GerdQ. This wasfollowed by serological evaluations and spirometry. Data was analysed using SPSS 21. RESULTS: Of the 459 subjects, 154(33.6%)were cases and305(66.4%)were controls.Amongthe cases, 81(52.6%)were females and 73(47.4%) were males with mean age 66.1±10.9 years. Among the controls, 162(53.1%) were females and 143(46.9%) were males with mean age 64.6±11.1 years(p>0.05.)The most common ethnicity wasUrdu-speaking; 89(58%) among the cases and 150(49%) among the controls (p<0.05). Ethnicity, number of persons in the household per room, and type of house were significantly associated with the risk of developing idiopathic pulmonary fibrosis(p<0.05). CONCLUSIONS: Ethnicity,type of house and the number of personsin a household perroom were found to be the significant risk factorsfor idiopathic pulmonary fibrosisIPF.

Visual Diagnosis of Pleural Tuberculosis and its Association with Tissue Biopsy, Culture and Xpert Assay.

INTRODUCTION: The diagnosis of pleural tuberculosis remains a clinical challenge due to the paucibacillary nature of disease. Medical thoracoscopy remains the gold standard in diagnosing tuberculous pleuritis. OBJECTIVE: To establish the diagnostic yield of sago-seed thoracoscopic appearance of pleura in tuberculosis and its correlation with histopathology, tissue AFB culture and tissue Xpert MTB/Rif assay. METHODS: All consecutive patients with lymphocytic exudative pleural effusion, who fulfilled inclusion criteria of the study underwent medical thoracoscopy under local anesthesia and pleural tissue was sent for histopathology, AFB culture and Xpert MTB/Rif assay. Chronic granulomatous inflammation on histopathology and response to anti-tuberculous treatment was taken as reference standard for diagnosis of tuberculous pleurisy. RESULTS: A total of 249 patients were included in the study, out of which 168 had effusion secondary to tuberculosis. Sago-like nodules visualized on thoracoscopy had a sensitivity of 58.9 %, specificity of 92.6 % and diagnostic accuracy of 69.88 % for pleural tuberculosis. There is a strong association between the presence of sago-like nodules and detection of mycobacterium tuberculosis on Xpert MTB/Rif assay and AFB culture of pleura (p-value 0.007). CONCLUSION: Sago seed nodules on pleura have a high positive predictive value for tuberculous pleurisy. In high endemic countries patients with this finding on thoracoscopy can be commenced on anti-tuberculous treatment before histopathology or culture results are available.

Comparison of DECAF (dysponea, eosinopenia, consolidation, acidaemia, and atrial fibrillation) and APACHE II (acute physiology and chronic health evaluation ii) scoring system to predict mortality among patients with acute exacerbation of chronic obstructive pulmonary disease.

OBJECTIVES: To compare the diagnostic accuracy of two systems in predicting mortality among patients with acute exacerbation of chronic obstructive pulmonary disease. METHODS: The cross-sectional study was conducted from November 2017 to June 2018 in the Department of Chest Medicine, Jinnah Postgraduate Medical Centre, Karachi, and comprised patients with acute exacerbation of chronic obstructive pulmonary disease. Dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation system was compared with acute physiology and chronic health evaluation II scoring system after mortality scores were calculated for each patient. Data was analysed using SPSS 21. RESULTS: Of the 210 patients, 147(70%) were males and 63(30%) were females. Overall, 59(28.1%) patients died during hospital stay. The mean dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation score was 2.31±0.93 while the mean acute physiology and chronic health evaluation II score was 15.8±7.2. A decision threshold of dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation score >2 had a sensitivity of 84.6% and specificity of 82.3% while acute physiology and chronic health evaluation II score had sensitivity of 53.9% and specificity of 76.5%. CONCLUSIONS: Both scoring systems were found to be good predictors of mortality, but dyspnoea-eosinopenia-consolidationacidaemia-atrial fibrillation score was a simpler and effective clinical tool.

Assessment and comparison of APACHE II (Acute Physiology and Chronic Health Evaluation), SOFA (Sequential Organ Failure Assessment) score and CURB 65 (Confusion; Urea; Respiratory Rate; Blood Pressure), for prediction of inpatient mortality in Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

OBJECTIVE: To assess and compare the role of Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Confusion Urea Respiratory Rate Blood Pressure scores in predicting inpatient mortality for patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease.. DESIGN: The retrospective study was conducted at the Jinnah Post-graduate Medical Centre, Karachi, and comprised data of all consecutive Acute Exacerbation of Chronic Obstructive Pulmonary Disease patients from December 1, 2013, to December 31, 2014. Logistic regression model and non-parametric tests were employed using SPSS 22.. RESULTS: There were 95 patients whose medical records were studied. The overall mean age was 60.79±12.39 years. Mortality rate was of 26(27.6%). Median hospital stay was 11.5 days (interquartile range: 9-17 days) in survivors and 4 days (2-8 days) in non-survivors. Out of the three scales used, Confusion Urea Respiratory Rate Blood Pressure-65 score showed the greatest difference between survivors and non-survivors (p <0.05). Significant higher scores were observed in non survivors with Type 2 than Type 1 respiratory failure (p<0.05). There was significant association of mortality with baseline partial pressure of oxygen and oxygen saturation (p<0.05 each). CONCLUSIONS: Confusion Urea Respiratory Rate Blood Pressure-65score determined at the time of admission had significant ability to predict inpatient mortality..

Standard factors predicting success of Non-invasive ventilation are useful in treating Patients with POST Tuberculosis sequel.

OBJECTIVE: The aim was to access the effectiveness of Bilevel Positive Airway Pressure (BiPAP) in patients with type II respiratory failure secondary to Post Tuberculosis (TB) sequelae and determine the factors that can predict its success. PostTB pulmonary sequelae are complications after healing of TB and type II respiratory failure is frequently encountered in this group. . METHODS: This prospective study was carried out in the department of Chest Medicine, Jinnah Postgraduate Medical Center Karachi. (JPMC) Total 78 patients, between 20-80 years of age having hypercapnic respiratory failure, were included. Patients were given BiPAP along with standard treatment. RESULTS: Among 78 patients, 45 (56.3%) were males and 33 (43.7%) were females. Patients mean age was 50.6 } 15.76 years. The BiPAP success rate was 70.5% (55/78). There is significant difference in age (p=0.008), duration of disease (p=0.021), baseline pH (p=0.00), PaCO2 (p=0.004), Glasgow Coma Score (p=0.031), Chest X-ray (p<0.05) and systolic blood pressure (p=0.007) between responders and non-responders. Improvement in Abgs and vitals was observed among responders following 3 hours of therapy while pH drops significantly at 3 hours in non-responders. CONCLUSIONS: This study reveals that BiPAP is also efficacious method in patients with Type II respiratory failure post TB sequelae. Potential non responders can be identified relatively early in course of treatment and considered for ventilator.

Establishing age specific spirometry reference ranges for children/adolescents of Karachi, Pakistan: Randomized trials.

OBJECTIVE: To establish age-specific normative spirometry reference range along with regression equation for children and adolescents. METHODS: The cross-sectional study was conducted from April to October 2017, and comprised children and adolescents aged 7-18 years at 8 educational institutions representing various socio-economic strata of Karachi. A modified version of the International Study of Asthma and Allergies in Childhood Questionnaire was used. Spirometry variables including forced vital capacity, forced expiratory volume in 1 second, ratio between the two, peak expiratory flow rate, forced expiratory flow between 25% and 75% expired volume were recorded and interpreted. By normal distribution curve the reference values were established, and mean}2 standard deviation values were taken as significant. Pearson's correlation coefficient and linear regression models were calculated for all pulmonary variables with age. RESULTS: Of the 751 subjects, 484(64.4%) were boys and 267(35.5%) were girls. The overall mean age was 12.96}2.8 years. The mean lung volume for forced vital capacity was 2.21}0.75, forced expiratory volume in 1 second 2.08}0.73, ratio between the two 92.9}4.7, peak expiratory flow 231.3 } 70.5 and forced expiratory flow between 25% and 75% expired volume was , , , 2.68}1.2. These lung volumes directly increased with age from children to adolescents (p<0.05). All variables showed a significant difference between boys and girls (p<0.05). CONCLUSIONS: There was a linear positive correlation of age with lung function variables, while the boys presented higher values than the girls.

Angiographic characteristics and in hospital outcome of young patients, age up to 40 versus more than 40 years undergoing primary percutaneous coronary intervention.

OBJECTIVE: To compare angiographic characteristics and outcomes of primary percutaneous coronary intervention between young and old patients presenting with acute ST Elevation Myocardial Infarction. METHODS: The prospective observational study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from December 17, 2016, to June 16, 2017, and comprised acute ST-Elevation Myocardial Infarction patients undergoing primary percutaneous coronary intervention (PCI). Data was collected on demographic, angiographic, and in-hospital outcomes. Those <40 years were considered young. Data was analysed using SPSS 21. RESULTS: Of the 415 patients, 50(12%) were young. Proportion of male was higher among the young (p=0.02) and so was the case with positive family history (p=0.002). The young had lesser cases of diabetes (p=0.028) and hypertension (p=0.034). Single vessel disease was more common among young (p<0.001). No significant difference was observed in post-procedure outcome related to age (p>0.05). CONCLUSIONS: Acute Myocardial Infarction in young was more likely associated with male gender, positive family history and less likely with hypertensive and diabetic status.

Procedural determinants of fluoroscopy time in patients undergoing cardiac catheterization.

BACKGROUND & OBJECTIVE: Due to increase in number of cardiac catheterization procedures safety concerns is an issue nowadays. Multiple diagnostic modalities use radiations, which also put a patient at higher cumulative radiation exposure. Therefore steps should be taken to minimize radiation exposure during cardiac catheterization. Hence determination of factors which prolong FT will result in better understanding of problem. This retrospective study was undertaken to determine factors responsible for prolong fluoroscopy time in patients undergoing coronary artery catheterization. METHODS: This retrospective study was conducted at catheterization Laboratory National Institute of Cardiovascular Diseases, Karachi from June 2014 to June 2015. Patients of either gender, aged between 18 to 90 years undergoing cardiac catheterization procedures were included. Radiation exposure time was measured in terms of fluoroscopy time. RESULTS: A total of 957 patients were included in this study out of which 731 were of diagnostic Coronary Angiograms (CA) and 226 were of Percutaneous Coronary Intervention (PCI). The mean age of the study participants was 54.12±10.89 years and majority 734(76.6%) were male. Mean fluoroscopy time (FT) in the patients subjected to PCI was 9.61±6.07 minutes while in cases for CA 4.17±4.13 minutes. FT for CA was observed significantly dependent on procedural access, operator's experience, and LV angiogram. While FT for PCI was found dependent on number of stents deployed during the procedure. CONCLUSION: For invasive coronary angiographic procedures radial route increased fluoroscopy time. For percutaneous coronary intervention femoral and radial route fluoroscopy time were not significantly different.

Factors affecting spirometry reference range in growing children.

OBJECTIVES: To find out the association of weight, height and age with spirometry variables and to generate a regression equation by taking weight as an independent variable beside age and height among children and adolescents of Karachi. METHODS: A modified form of ISSAC questionnaire was used. The spirometry variables recorded were Forced vital capacity (FVC), Forced expiratory volume in 1 second (FEV1), FEV1/FVC, Peak expiratory flow rate (PEF), Forced expiratory flow between 25% and 75% expired volume (FEF25-75). A person's correlation coefficient among boys and girls were calculated for all spirometry variable considering age, height and weight as independent variables. The linear regression models were calculated. RESULTS: The results reported a linear correlation of lung function variables with all three independent variables (i.e. p-value = 0.000), in which age and height manifested a strong positive correlation while weight reported a moderately significant correlation. All spirometry variables such as FVC, FEV1, PEF and FEF25-75 reported a significant coefficient of dependency and coefficient of correlation individually with age, height and weight. CONCLUSION: It is concluded that beside age, height and weight both also have significant correlation with lung volumes so these should be taken into account when using spirometry as a diagnostic test.

Effectiveness and Quality of Life with Montelukast in Asthma - A double-blind randomized control trial.

OBJECTIVE: To determine the role of montelukast - a leukotriene receptor antagonist (LTRA) - in improving the quality of life (QOL) and asthma control of adult patients with mild to moderate persistent asthma. METHODS: Randomized, double-blind, placebo-controlled, non-crossover trial was conducted from March 2017 till November 2018 in three hospitals of Karachi and Hyderabad. Adults of age 15 years or more with mild to moderate persistent asthma. Treatment group was administered tablet montelukast 10mg once daily; the other group was given a similar looking placebo; as an adjuvant to the current medication. QOL was assessed with Asthma Quality of Life Questionnaire - Standard (AQLQ-S) before and after the treatment. Asthma control was monitored via Asthma Control Test (ACT). RESULTS: After 4 weeks, the mean ± SD of overall QOL on AQLQ-S improved from 3.74±0.88 to 5.06±0.89 for montelukast group and from 3.58±0.92 to 4.71±0.97 for placebo group (p=0.02). The improvement in sub-domains of symptoms, activity, and emotional functions was not significant; however, the sub-domain "environmental stimuli" significantly improved with 5.06±0.89 for montelukast group and 4.71±0.97 for placebo group (p=0.02). The mean ± SD of ACT, after four weeks, for montelukast group was 18.19±2.91 and for placebo group 17.28±3.36. Only on ACT, Montelukast did not show any statistically insignificant results. CONCLUSION: The role of montelukast in improving QOL of adult patients with mild to moderate persistent asthma is quite beneficial. It improves patient quality of life. It has the ease of once daily oral administration and also eradicates side effects associated with long-term adherence to steroids.

Role of medical Thoracoscopy in the Management of Multiloculated Empyema.

BACKGROUND: The treatment of early pleural empyema depends on the treatment of ongoing infection by antimicrobial therapy along with thoracocentesis. In complicated empyema this treatment does not work and lung will not expand until removal of adhesions. The objective of the current study is to analyze the experience of management of multiloculated, exudative and fibrinopurulent empyema through rigid medical thoracoscopy under local anaesthesia and to explore new ways to manage the entity. METHODS: This is a descriptive case series in which 160 patients were recruited through non-probability convenient sampling, from department of pulmonology, Jinnah postgraduate medical centre, Karachi, from September 2014 to August 2016. All patients underwent medical thoracoscopy under local anesthesia. Written Informed consent was taken from the study participants. Ethical approval was obtained from Ethical Review Committee of the hospital. Patients age > 70 years, those with multiple organ failure and bleeding disorders were excluded. RESULTS: Out of 160 patients, 108 (67.50%) were male and 52 (32.5%) were female with mean age 25.37 years (range 16 to 70 years). Out of total, 102 (63.7%) had tuberculous empyema, while pleural biopsy of 58 (36.3%) patients was suggestive of non-tuberculous empyema. Final evolution through chest x-ray revealed complete resolution in 92 (57.5%), partial resolution in 58 (36.25%) patients. 9 (5.6%) developed persistent air leak while 1 (0.6%) patient expired due to urosepsis. CONCLUSION: Medical Thoracoscopy under local anesthesia is a safe, efficient and cost effective intervention for management of complicated empyema, particularly in resource constraint settings.

Managed successfully: Iatrogenic aortic dissection during primary percutaneous coronary intervention.

Iatrogenic aortic dissection caused by primary percutaneous coronary intervention (PCI) is a rare but potentially fatal complication; therefore prompt recognition of this life-threatening condition is crucial. We present herein a case of a 70-year-old lady who underwent primary PCI for transmural myocardial infarction of left anterior descending artery territory. Manipulation of the extra backup (EBU) guiding catheter during an attempt to cannulate the left system resulted in an aortic dissection. The patient was managed conservatively with strict monitoring in the coronary care unit (CCU), and underwent serial evaluation with non-invasive imaging studies including a computed tomography angiography (CTA). On the 3rd post-procedure day, she developed cerebrovascular accident from which she recovered completely. Repeat CT angiogram showed complete resolution of the ascending aortic dissection. Initial follow-up was conducted at 2 weeks and the patient was doing well.

Interstitial Lung Diseases Misdiagnosed as Tuberculosis.

OBJECTIVE: To determine the frequency of misdiagnosis of tuberculosis in interstitial lung disease cases. METHODS: This is a prospective study including patients registered in the interstitial lung disease clinic, Jinnah Postgraduate Medical Center, Karachi, during May-June 2017. Diagnosis of tuberculosis was only confirmed if there was any bacteriological evidence of tuberculosis at the time of diagnosis or if there was improvement in symptoms after treatment in patients diagnosed as having tuberculosis on clinical grounds. RESULTS: Seventy-three patients were included in the study, out of which 53 (72.60%) were females and 20 (27.39%) were males. Tuberculosis was treated before presentation in 28 (38.35%) of interstitial lung disease patients. Except for two silicosis patients who had smear positive tuberculosis, rest of the patients were misdiagnosed as having tuberculosis. CONCLUSION: Interstitial lung diseases are the disorders that are frequently unrecognized and misdiagnosed. More commonly the confusion is with tuberculosis. Thorough knowledge about interstitial lung diseases should be provided to the primary care physicians, especially in countries with high tuberculosis burden, so that to limit maltreatment with anti-tuberculous drugs when they are not needed and early referral to interstitial lung disease clinic.

Knowledge of female doctors about smoking risks and their attitude toward cessation in antenatal clinics - perspective from tertiary care hospitals in Karachi.

OBJECTIVE: To assess the knowledge and attitude of doctors with regard to smoking risks and cessation, and to identify factors associated with self- reported assessment of smoking. METHODS: This cross-sectional survey was performed in 5 hospitals of Karachi from February to April 2014, and comprised doctors providing antenatal care. Data was collected using a questionnaire. SPSS 21 was used for data analysis. RESULTS: Of the 164 respondents,150(91.5%) considered the assessment of smoking an integral part of their medical responsibilities, but only 53(32.4%) reported that they asked regarding smoking habit in 100% of patients and 77(47.3%) inquired about passive smoking. The mean knowledge score for risks and cessation was 2.57±0.278 and 2.12±0.457, respectively. A few misconceptions were also found, such as 94(57.3%) doctors were against the use of nicotine replacement therapy in pregnant females and 114(69.4%) falsely believed that smoking was associated with pre-eclampsia. Factors independently associated with good baseline knowledge were: formal training (p=0.01) and hospital's smoke-free policy (p=0.004). Doctors with formal training more frequently assessed smoking habit of their patients and were more confident while counselling patients for smoking cessation (p=0.05). CONCLUSIONS: Basic misconceptions showed inadequate knowledge among doctors working in antenatal clinics.

Application of BiPAP through Endotracheal Tube in Comatose Patients with COPD Exacerbation.

OBJECTIVE: To evaluate the effectiveness and safety of using BiPAP through endotracheal tube in comatose Chronic Obstructive Pulmonary Disease (COPD) patients with hypercapnic respiratory failure. METHODS: This is a prospective study done at Department of Chest Medicine, Jinnah Postgraduate Medical Centre, Karachi, during March to June 2017. It included all comatose COPD patients with hypercapnic respiratory failure who had a poor functional status prior to the illness and who did not meet the criteria to be kept on mechanical ventilator. Patients with apnea and other causes of coma were excluded. These patients were applied BiPAP through endotracheal tube and its response on blood gases and neurological status was evaluated. RESULTS: The success rate of BiPAP through endotracheal tube was 70.5% (31/44). Improvement in Glasgow Coma Scale (GCS) score (p<0.01), pH (p<0.01), and PaCO2 (<0.01) was observed among the responders following two hours and 24 hours of therapy. No significant difference was found in response with regards to gender, smoking status, prior use of noninvasive ventilation or duration of disease. No complications were observed during the therapy. CONCLUSION: In resource poor settings, the use of BiPAP through endotracheal tube can be an effective and safe intervention for comatose COPD patients with hypercapnic respiratory failure.

Management of community acquired pneumonia by Family Physicians.

BACKGROUND AND OBJECTIVE: Community Acquired Pneumonia (CAP)is a major burden on health systemwith significant mortality and morbidity. Family Physicians(FPs)can play important role. To determine management strategies and prescription of FPs regarding CAP. METHODS: A multicenter cross sectional survey was done in 10 cities of Pakistan from November 2014 to January 2015. Self-administered questionnaire was filled by 110 Family Physicians. RESULTS: Of total 71% of FPs reported to work in high prevalence areas for respiratory ailments. Only 32% of FPs used PSI and 34% CURB 65 for assessment of severity. It was alarming to note that only 58% of FPs treats severe pneumonia with Intravenous antibiotics while rests were comfortable with oral route. The overall use of quinolones to treat CAP, irrespective of severity, in combination or as single agent was > 60%. Duration of antibiotics for severe pneumonia was sub optimal (<10 days). Only 52.8% patients came back for follow-up so true outcome cannot be anticipated. CONCLUSION: Major deficiencies were treatment of severe pneumonia in community, inappropriate use of quinolones and poor knowledge of recent guidelines. This can lead to emergence of resistant bacteria and high mortality and morbidity. List of Abbreviations: FPs: Family Physicians, CAP: Community Acquired Pneumonia.

Safety of primary percutaneous coronary intervention with and without (selective) thrombus aspiration.

OBJECTIVE: To determine the safety and efficacy of selective thrombus aspiration during Primary Percutaneous Coronary Intervention (PCI). METHODS: This observational prospective study was conducted in the catheterization laboratory of a tertiary care cardiovascular centre. A total of 150 consecutive patients who underwent primary PCI were enrolled. Aspiration was done only when thrombus burden was considered significant. After completion of procedure angiographic and electrocardiographic signs were recorded and clinical follow up was documented up to 1 year. RESULTS: No significant difference among the groups was found in age, height, weight and other risk factors like Hypertension, Diabetes Mellitus and Smoking. In general, left anterior descending artery was culprit in - 65% of patients and more than 90% of culprit vessels had visible thrombus. Multivessel disease was present in 38% of patients and 22.7% had past history of myocardial infarction. Out of 150 patients 117 (78%) underwent thrombus aspiration. No significant difference was found in ST resolution within 60 minutes (72.6 vs 81.8%; P < 0.285) and myocardial blush grade II & III (41.9 vs 27.3%; P < 0.128). No difference in event free survival was observed among the two groups (80.3 vs 84.8%; P < 0.708) at one year. CONCLUSION: Selective thrombus aspiration in definite thrombus laden arteries and no aspiration in low or negligible thrombus burden vessels may be a safe and effective strategy in patients undergoing primary PCI. Overall poor risk profile of our patients as compared to western population necessitates further evaluation of this matter in randomized studies.

Comparison of plasma from healthy nonsmokers, smokers, and lung cancer patients: pattern-based differentiation profiling of low molecular weight proteins and peptides by magnetic bead technology with MALDI-TOF MS.

CONTEXT: Smoking is the major contributor of lung cancer (LC), which accounts for millions of death. OBJECTIVE: This study focused on the correlation between the proteomic profiling of LC patients, and healthy nonsmokers and smokers. METHOD: Pattern-based peptide profiling of 186 plasma samples was performed through reversed-phase chromatography-18 magnetic bead fractionation coupled with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry analysis and resulted data were evaluated statistically by ClinProTool. RESULTS: Marker peaks at m/z 1760, 5773, 5851, 2940, and 7172 were found with an excellent statistical figure. CONCLUSION: Selected marker peaks can be served as a differentiated tool of LC patients with high sensitivity and specificity.

Role of APACHE score in predicting mortality in chest ICU.

OBJECTIVE: To determine the first 24 hours mean values of APACHE II score for two outcomes (alive or dead) in patients admitted in chest ICUs. METHODS: A prospective study was conducted in the Department of Chest, Jinnah Postgraduate Medical Centre Hospital, Karachi from January 2009 to December 2009. Patients of all ages and either gender admitted in chest ICU for any cause, were consecutively enrolled. All patients with incomplete records and missing variables including laboratory investigations or who had not been followed up due to any reason were excluded. Patients who were readmitted in the ICU were also excluded. The main outcomes were the first 24 hours mean APACHE II score of the sample and first 24 hours mean APACHE II score of patients who were later discharged or had died. RESULTS: The mean age of the patients was 53.16 +/- 19.29 years. Out of 143 participants 84 (58.7%) were males and 59 (41.3%) females. The main diagnosis included COPD with acute exacerbation 63 (44.05%), post TB fibrosis 17 (11.88%), acute severe asthma 14 (9.79%) and pneumonia 12 (8.39%) patients. The results found that 63 out of 143 patients were alive whereas 80 patients died. The mean APACHE II score on first 24 hours was 20.09 +/- 7.49. The mean 24 hours APACHE II score of patients who were discharged and who died was 18.93 +/- 7.19 and 22.33 +/- 7.80 respectively. CONCLUSION: Our preliminary results showed that it is recommended to determine the cut off levels of APACHE II scores in patients admitted with chest ICU.

Tracheobronchopathia osteochondroplastica: a cause of chronic cough and haemoptysis.

Tracheobronchopathia osteochondroplastica (TPO) is a rare disorder of the tracheopulmonary tree characterised by osseous and cartilaginous submucosal nodules projecting into the tracheal lumen, sparing the posterior tracheal membranous wall. Symptoms are non-specific and may include dry cough, hoarseness, dyspnoea, recurrent pneumonia and occasionally haemoptysis. A fibreoptic bronchoscopy showing multiple tracheal nodules followed by pathological biopsy is required to reach the final diagnosis. Here, we report two cases of TPO, both with history of biomass fuel exposure and almost similar clinical presentions with chronic cough, shortness of breath and intermittent haemoptysis. They both underwent fibreoptic bronchoscopy showing multiple tracheal nodules whose histopathological analysis showed the diagnosis of TPO. Both patients were treated conservatively and remained in good health afterwards. Physicians should be aware about the need of advanced surgical procedures including endotracheal stent placement in more severe cases.