An unusual case of nonspecific interstitial pneumonia treated initially with surgical resection.

Nonspecific interstitial pneumonia (NSIP) has been recently described as a distinct clinicopathologic entity. We describe an unusual case of a middle-aged man who presented with exertional dyspnoea, cough, radiographic airspace opacities in the left lung and previous history of right thoracotomy for suspected right lower lobe neoplasm. Histology at that time revealed "chronic inflammation". A course of high-dose steroids was given after failure of the airspace opacities to respond to a trial of antituberculous therapy. Improvement in symptoms and radiological appearance was noted subsequently. A diagnosis of nonspecific interstitial pneumonia was made on review of the initial open lung biopsy specimen. Seven months after tailing down to maintenance low-dose steroids, the NSIP relapsed. The NSIP subsequently responded again to high-dose steroids. This case illustrates that NSIP is a difficult diagnosis, may present as a focal lung opacity initially, and may relapse after steroid dose is tailed down.

Occupational asthma in Singapore.

AIM: Since the first notified case of occupational asthma in 1983, a total of 90 cases were confirmed as on 31st December 1999. In this study, demographic data, causative agents and impact on the workers were described. METHODS: The data was derived from notifications to the Ministry of Manpower and referrals to the Occupational Lung Disease Clinic jointly run with Department of Respiratory Medicine, Tan Tock Seng Hospital. RESULTS: Of the 90 cases, 19 (21%) were females and 71 (79%) were males. There were 48 (53%) Chinese, 22 (24%) Malays, 14 (16%) Indians and 6 (7%) of other ethnic origins. The mean age at diagnosis was 35.8 +/- 9.3 yrs. The mean duration of exposure prior to onset of symptoms was 34.9 +/- 57.3 months. The most common causative agent was isocyanates (28 cases, 31%) followed by solder flux (12 cases, 13%) and welding fumes (8 cases, 9%) respectively. Thirteen (14.4%) workers were assessed to have permanent disability under the Workmen's Compensation Act. CONCLUSIONS: Since 1990, occupational asthma has overtaken silicosis and asbestosis as the most common occupational lung disease in Singapore. The most common causative agent is isocyanates. Occupational asthma is a condition associated with disability in the workplace and may still be largely under-reported.

Audit of oxygen therapy in acute general medical wards following an educational programme.

INTRODUCTION: Previous studies have shown that the administration of supplementary oxygen (O2) in hospitalised patients outside the intensive care units (ICU) was usually empirical, inappropriate and not in compliance with physiological guidelines. It has been suggested that routine use of portable pulse oximeters in general wards plus in-service education of doctors and nurses may ameliorate this problem. MATERIALS AND METHODS: We introduced the use of pulse oximeters in general wards and instituted an educational programme on O2 therapy in a University Hospital. We then audited the process of O2 therapy in 100 consecutive adult medical inpatients. RESULTS: We found that, despite an educational programme and the easy availability of pulse oximeters, the quality of O2 therapy was poor. Half the patients did not receive objective pre-treatment assessment while 43% of patients were not adequately reassessed after O2 supplementation had been started. The most common error was excess use of O2 which occurred in 75% of patients. CONCLUSION: The quality of O2 therapy in the non-ICU setting was poor. Excessive O2 use was the most common error. We suggest that titration of O2 therapy, guided by pulse oximeter-guided protocols, may be needed to improve the quality and reduce the cost of O2 therapy in the hospital. This intervention may best be instituted within the environment of a continuous quality improvement model of health care delivery.