Clinical outcomes of multidisciplinary care in chronic obstructive pulmonary disease patients at the Central Chest Institute of Thailand.

OBJECTIVE: To compare clinical outcomes before and after are enrolled study within 1 year and factors related to Chronic Obstructive Pulmonary Disease (COPD) exacerbations after enrolled. MATERIAL AND METHOD: COPD patients who were compatible with inclusion criteria in COPD clinic at the Central Chest Institute of Thailand between March 2007 and July 2010. Baseline characteristics, COPD management program, bronchodilator used, and clinical outcomes were recorded by a search of retrospective databases, as well as the patient medical records. RESULTS: A total of 247 enrolled patients compatible with inclusion criteria were analyzed. Most of the patients were male, 240 patients (97.2%). The average age of the patients was 69.3 +/- 9.1 years. The majority of patients were in GOLD stage II, 121 patients (49.0%). After multidisciplinary care was performed. In an overall 219 patients (88.6%) of COPD patients received appropriate bronchodilator treatment classified by GOLD stage which had different proportions in each stage significantly [stage I = 45 patients (100%), stage II = 103 patients (86.6%), stage III = 58 patients (86.6%), stage IV = 13 patients (92.8%),p = 0.026]. COPD exacerbations frequency (0.9 +/- 1.6 vs. 0.3 +/- 0.9, p<0.001), COPD related-hospitalizations (0.2 +/- 0.8 vs. 0.1 +/- 0.4, p < 0.001), COPD related-respiratory failure (0.04 +/- 0.25 vs. 0.008 +/- 0.090, p = 0.020) were significantly decreased after enrolled. On multivariate analysis, COPD patients who had exacerbations frequency more than one time per year were prone to have repeated COPD exacerbations approximately three times more than other COPD patients (Adjusted Odds ratio 2.80, 95% CI, 1.08 to 7.26, p = 0.034). CONCLUSION: Multidisciplinary care in COPD patients can significantly improve clinical outcomes.

Accuracy of endobronchial ultrasound guided-transbronchial needle aspiration in mediastinal lymph node diagnosis.

OBJECTIVE: To evaluate the efficacy of Endobronchial ultrasound guided-transbronchial needle aspiration (EBUS-TBNA) for biopsy specimens with adequate evaluable lymphocytes and mediastinal lymph node diagnosis. MATERIAL AND METHOD: Prospective cohort study. Over 18 year old patients with mediastinal or hilar lymphadenopathy, with short axis diameter greater than 10 mm on chest CT were indicated to undergo EBUS-TBNA. When a node was detected, an aspiration was performed under ultrasound guided. The primary end point was the percentage of biopsy specimen with adequate evaluable lymphocytes that had been evaluated by cytopathologist. Secondary endpoint was the percentage of EBUS-TBNA diagnosis result. RESULTS: 82 patients with mediastinal or hilar lymphadenopathy underwent EBUS-TBNA. Average size of lymph node was 1.57 x 1.49 cm. The overall of the diagnostic accuracy was a percentage of biopsy specimen with adequate evaluable lymphocytes as 97.7%. For mediastinal lymph node diagnosis, the cytological evaluation demonstrated that the positive for malignancy, atypical or suspicious for malignancy, negative for malignancy and non-diagnosis were 37.2%, 9.3%, 2.3% and 51.2%, respectively. In case of positive for malignancy, non-small cell carcinoma, adenocarcinoma, bronchoalveolar cell carcinoma and small cell carcinoma were found 62.5%, 15.6%, 3.1% and 18.8%, respectively. Additionally, the pathological examination showed that positive for malignancy, atypical or suspicious for malignancy, negative for malignancy and non-diagnosis were found 35.4%, 7.3%, 3.6% and 53.7%, respectively. There were no complications during all of the procedures. CONCLUSION: High percentage of biopsy specimen with adequate evaluable lymphocytes can be obtained in EBUS-TBNA. This finding suggested that this method should be considered for mediastinal lymph node diagnosis.

An outbreak of botulism in Thailand: clinical manifestations and management of severe respiratory failure.

BACKGROUND: Northern Thailand's biggest botulism outbreak to date occurred on 14 March 2006 and affected 209 people. Of these, 42 developed respiratory failure, and 25 of those who developed respiratory failure were referred to 9 high facility hospitals for treatment of severe respiratory failure and autonomic nervous system involvement. Among these patients, we aimed to assess the relationship between the rate of ventilator dependence and the occurrence of treatment by day 4 versus day 6 after exposure to bamboo shoots (the source of the botulism outbreak), as well as the relationship between ventilator dependence and negative inspiratory pressure. METHODS: We reviewed the circumstances and timing of symptoms following exposure. Mobile teams treated patients with botulinum antitoxin on day 4 or day 6 after exposure in Nan Hospital (Nan, Thailand). Eighteen patients (in 7 high facility hospitals) with severe respiratory failure received a low- and high-rate repetitive nerve stimulation test, and negative inspiratory pressure was measured. RESULTS: Within 1-65 h after exposure, 18 of the patients with severe respiratory failure had become ill. The typical clinical sequence was abdominal pain, nausea and/or vomiting, diarrhea, dysphagia and/or dysarthria, ptosis, diplopia, generalized weakness, urinary retention, and respiratory failure. Most patients exhibited fluctuating pulse and blood pressure. Repetitive nerve stimulation test showed no response in the most severe stage. In the moderately severe stage, there was a low-amplitude compound muscle action potential with a low-rate incremented/high-rate decremented response. In the early recovery phase, there was a low-amplitude compound muscle action potential with low- and high-rate incremented response. In the ventilator-weaning stage, there was a normal-amplitude compound muscle action potential. Negative inspiratory pressure variation among 14 patients undergoing weaning from mechanical ventilation was observed. Kaplan-Meier survival analysis identified a shorter period of ventilator dependency among patients receiving botulinum antitoxin on day 4 (P=.02). CONCLUSIONS: Patients receiving botulinum antitoxin on day 4 had decreased ventilator dependency. In addition, for patients with foodborne botulism, an effective referral system and team of specialists are needed.

Functional outcomes in patients with REM-related obstructive sleep apnea treated with positive airway pressure therapy.

STUDY OBJECTIVES: To evaluate functional outcomes in adults with REM-related obstructive sleep apnea (OSA) treated with positive airway pressure (PAP) therapy. DESIGN: Retrospective observational study. SETTING: Outpatient sleep clinic. PATIENTS: 330 adults (171 males) with OSA receiving PAP therapy, including 130 with REM OSA and 200 with OSA not restricted to REM. MEASUREMENTS AND RESULTS: REM OSA was defined as a REM apnea-hypopnea index (AHI) / NREM AHI > 2 and NREM AHI < 15. Patients had baseline and post-PAP functional outcomes, including Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), Patient Health Questionnaire-9 (PHQ-9), and Functional Outcomes Sleep Questionnaire (FOSQ) scores. We compared functional outcomes, demographic, clinical and polysomnographic features, and PAP adherence in patients with REM OSA and OSA not restricted to REM. Female gender was significantly more common in REM OSA. Age, BMI, neck girth, and baseline ESS, FSS, PHQ-9, and FOSQ were similar between groups. Smoking history and comorbid disorders were also similar except for a higher prevalence of depression and cardiovascular disease in OSA not restricted to REM. All functional outcomes improved significantly after PAP therapy in both groups. Change from baseline to post treatment was similar for all functional outcomes between groups. CONCLUSIONS: The study is the first addressing clinical outcomes in REM OSA using validated measures. Functional outcomes in patients with REM OSA improve after treatment with PAP therapy comparable to that observed in patients with OSA not restricted to REM. COMMENTARY: A commentary on this article appears in this issue on page 249.