Simplifying STOP-BANG: use of a simple questionnaire to screen for OSA in an Asian population.

OBJECTIVE: We aim to assess the utility of a simple-to-use 8-point questionnaire in screening for moderate-severe obstructive sleep apnea (OSA) and to assess the validity of cutoffs used to score body mass index (BMI) in this questionnaire. METHODS: Patients undergoing diagnostic polysomnography (PSG) were asked to fill in a questionnaire with a simple dichotomized 8-point questionnaire, represented by the mnemonic STOP-BANG. A score of 3 or more out of a possible 8 was taken to indicate high risk for presence of OSA. These were then evaluated versus results from the overnight, monitored PSG. RESULTS: Three hundred and forty-eight patients underwent overnight diagnostic PSG, of whom 319 (91.2%) completed the questionnaire. Seventy-four (22.7%) were classified as being at low risk of OSA and 252 (77.3%) were classified as being high risk. The sensitivities of the STOP-BANG screening tool for an AHI of >5, >15, and >30 were 86.1%, 92.8%, and 95.6%, respectively, with negative predictive values of 84.5% and 93.4% for moderate and severe OSA, respectively. Using cutoffs of 30 or 35 for scoring the BMI did not significantly change the performance of the screening tool. CONCLUSION: STOP-BANG is a clinically useful tool with high sensitivity that can be used to screen patients for moderate and severe OSA. Using cutoffs of 30 for BMI, 40 cm for neck circumference, and 50 years for age simplifies the application of the tool without affecting performance.

Fluoroquinolones may delay the diagnosis of tuberculosis.

INTRODUCTION: Fluoroquinolones (FQs), frequently used for many common infections such as community-acquired pneumonia and urinary tract infection, are also effective against Mycobacterium tuberculosis. This study describes a series of patients in whom the empirical use of FQs for what appeared to be common community-acquired infections led to a delay in the diagnosis of tuberculosis (TB). METHODS: We reviewed the records of five patients with TB in whom the early use of FQs led to partial symptom resolution and a prolonged relapsing and remitting course. RESULTS: Of the five patients described, four presented with community-acquired pneumonia and one with urinary tract infection. All were given FQs and improved, though not completely. Their illnesses took a relapsing and remitting course. TB was eventually diagnosed, in four of them by culture and in one by characteristic histopathology (this patient required surgical resection of a lung abscess). CONCLUSION: FQs may lead to partial symptom resolution in TB. We highlight the problem of a delayed diagnosis, and voice our concern about inadvertent monotherapy of TB in such cases.

Cavitating cryptococcal pneumonia in the immunocompetent host.

INTRODUCTION: Isolated cryptococcal pneumonia in the immunocompetent host is a rare infection. Indications for treatment and its duration are currently not defined. CLINICAL PICTURE: Three patients presented with cavitating cryptococcal pneumonia. TREATMENT: They were treated with oral fluconazole. OUTCOME: Improvement was evident clinically, radiologically and serologically. Fluconazole was continued until serum cryptococcal antigen (SCA) levels were negative in our patients as they had manifestations such as haemoptysis, cavitating or multi-lobar pneumonia and relatively high antigen levels, suggesting potentially serious disease. CONCLUSIONS: Fluconazole is effective and safe for the treatment of cryptococcal pneumonia in the immunocompetent host. Although the role of monitoring SCA levels in the immunocompetent host is currently unclear, it may be an indication of infective burden and the benefits of longer treatment seem to outweigh the risks.

Lower Respiratory Tract Adenoid Cystic Carcinoma: Its Management in the Past Decades.

AIMS: Adenoid cystic carcinoma of the lower respiratory tract is a rare indolent neoplasm with prolonged survival, propensity for recurrences and metastasis years after initial therapy. We aim to study a 1,700-bed single tertiary academic hospital's long-term experience with ACC of the lower respiratory tract from the larynx to the lungs and review published literature on this subject. MATERIALS AND METHODS: We analysed the clinicopathology, treatment options and outcome in 33 patients and reviewed the published literature over the last five decades. RESULTS: The tumour has no gender predilection, a peak incidence in the fifth decade and is not related to smoking. Insidious symptoms are often treated as benign obstructive airway disease and infection; negative signs and normal chest X-rays delayed diagnosis. The tumour was distributed most commonly in the trachea followed by main bronchi, lobar bronchi and larynx. About 22% of patients required emergent bronchoscopic intervention to secure airway patency before definitive therapy with surgery or/and radiotherapy. A high proportion of resected specimens had positive margins. Overall survival and disease-free survival rates at 5 years were 81 and 62%, respectively, and at 10 years 70 and 54%, respectively. Prolonged good palliation was achieved for patients with unresectable lesions with radiation and wide armamentarium of endoscopic therapy. CONCLUSIONS: In time, many patients eventually succumb to this disease. However, advances in medical skill and technology have prolonged survival while maintaining a good quality of life. Adenoid cystic carcinoma of the respiratory tract is a chronic life-long disease that may require interval intensive therapy. The challenge is to find the best therapeutic regimen aiming for a 'true' cure. Further study on the mutational landscape of adenoid cystic carcinoma may provide potential avenues for novel treatments to address a chemoresistant cancer.

"Postpolio" sequelae and sleep-related disordered breathing.

OBJECTIVE: To analyze the clinical manifestations and various types of sleep-related disordered breathing (SRDB) in patients with a history of poliomyelitis and with current "postpolio" sequelae (PPS). MATERIAL AND METHOD: We retrospectively reviewed the medical records of 108 consecutive patients with PPS and sleep disturbances encountered during an 11-year period at Mayo Clinic Rochester and abstracted the features of acute polio, PPS, and results of sleep evaluation (overnight oximetry or polysomnography). Only those patients who were not receiving ventilatory support were included in the study. RESULTS: The features of PPS were dyspnea, fatigue, new weakness, and musculoskeletal pain. Of the 108 patients, 35 fulfilled the inclusion criteria. Sleep evaluations revealed three general types of disturbances: obstructive sleep apnea (group O, N = 19); hypoventilation (group H, N = 7); and both (group OH, N = 9). The mean apnea/hypopnea index was 37, 4, and 16 per hour in patients in groups O, H, and OH, respectively (P < 0.05), and the mean arterial carbon dioxide tension was 39, 60, and 55 mm Hg in these respective study groups (P < 0.05). The overall mean age at onset of symptoms of SRDB was 47 years, and the mean latent period after acute polio was 37 years. Hypersomnolence was the commonest SRDB symptom, present in 32 of the 35 patients. Snoring was noted in 100% of patients in group O, 0% in group H, and 67% in group OH. Patients in group O were obese and had normal lung function. Patients in group H tended to have normal weights and a history of diffuse neurologic deficits involving the trunk during the acute episode of polio. Scoliosis, restricted lung function, cor pulmonale, and decreased maximal respiratory pressures were common in patients in group H. Patients in group OH had overlapping features of those in groups O and H. CONCLUSION: In patients with PPS, we identified three patterns of sleep disturbances--obstructive sleep apnea, hypoventilation, and a combination of both. These groups are characterized by clinical features and by results of arterial blood gas determinations, overnight oximetry, and polysomnography. SRDB is a late sequela of poliomyelitis, and clinical evaluation should include information about sleep.

Treatment of severe carinal stenosis with overlapping metallic endoprosthesis.

A 50-year-old man presented with respiratory distress from central airway compression secondary to malignant mediastinal adenopathy. The stenosis involved the carinal triangle and created residual luminal diameters of 6 mm, 6 mm, and pinhole in the distal trachea and right and left mainstem bronchi, respectively. Airway patency at the carina was restored successfully with a stenting method that uses two overlapping Wall stents.

Smoking cessation programme: the Singapore General Hospital experience.

INTRODUCTION: The National Health Survey in Singapore reported that the prevalence of smoking had decreased from 20 percent in 1984 to 15 percent in 1998. This may be due to the efforts of smoking cessation education established island-wide. In this study, we review the efficacy of the Singapore General Hospital smoking cessation programme and examine the efficacy of different treatment modalities. METHODS: We studied the immediate quit rate and point prevalence abstinence rates at six and 12 months in our telephone survey. Subjects were patients who attended our programme from June 1999 to December 2002. Pharmacotherapeutic aids utilised with counselling sessions were individualised. RESULTS: The study populations for outpatient and inpatient arms were 394 patients and 425 patients, respectively. In the outpatient programme, mean age was 46 years (range of 12 to 80 years), and the ratio between males and females was 8.6. The outpatient immediate quit rate was 33 percent, and the six and 12 month quit rates were both 36 percent. However, in the inpatient programme, mean age was 65 years (range of 15 to 93 years), and the ratio between males and females was 4.9. The six and 12 month quit rates of the inpatient arms were 30 percent and 32 percent, respectively. Although there is no statistically significant difference in the different treatment modalities, the immediate quit rates for bupropion only and counselling only were relatively higher (36 percent and 41 percent, respectively). These were sustained at more than 35 percent at six and 12 months follow-up. We achieved comparable efficacy compared to published data. Counselling, as a sole therapy, can be effective in a select patient group. One-time inpatient counselling achieved a quit rate (32 percent at 12 months) far superior to previously-reported self-quit rate (3 percent and 8 percent at 12 months). CONCLUSION: We strongly recommend that all inpatients who are smokers to be routinely referred for counselling.

Retinal artery occlusion in a diver.

The clinical manifestation of decompression disorders is highly variable, ranging from mild rashes or joint pains to central nervous system symptoms like scotomata, paralysis and death. The diagnosis is easily overlooked, especially if an occupational history is not obtained. Recompression treatment with hyperbaric oxygen is the specific treatment for decompression sickness and air embolism. Prompt recognition and treatment are vital to recovery. However, there is a place for treatment of decompression disorders and embolism even when significant delay of up to 14 days has occurred. This case report discusses decompression disorders in relation to an unskilled fisherman diver who present with retinal artery occlusion. Decompression disorder leading to retinal artery occlusion is a very rare presentation. The difficulty of diagnosis is discussed as well as the result of delayed hyperbaric treatment.

Endobronchial stenting in patients requiring mechanical ventilation for major airway obstruction.

OBJECTIVE: To examine the value of therapeutic rigid bronchoscopy on subsequent ventilator weaning in ventilated patients with major airway obstruction. MATERIALS AND METHODS: Retrospective review of the medical records of patients who were receiving mechanical ventilation up to the time of rigid bronchoscopy over the period from September 1994 to January 1999. The setting is in an acute tertiary hospital. All patients underwent rigid bronchoscopy with endoscopic techniques (forceps removal, balloon dilation Nd:YAG laser resection and stent insertion) aimed at restoration of major airway patency. RESULTS: Seven patients were identified; 2 with benign stenosis and 5 with malignant stenosis. Six out of the 7 patients had presented with acute respiratory distress requiring emergent intubation, whilst 1 patient had extubation difficulties following general anaesthesia with endotracheal intubation. Three out of the 7 patients had previously failed extubation attempts. All 7 patients were successfully extubated within 48 hours following the procedure. CONCLUSIONS: Therapeutic rigid bronchoscopy is effective in the acute management of respiratory distress from central airway obstruction. Dramatic improvements in ventilatory status following therapeutic rigid bronchoscopy allow ventilator liberation in a select group of patients with an otherwise good performance status.

Oral glucose tolerance test--can the reflectance meter replace laboratory-based methods?

Sixteen national servicemen detected to have glycosuria on routine medical examination were subjected to 3 successive oral glucose tolerance tests. Capillary blood glucose was measured by reflectance meter in the first test (oGTT1), venous whole blood glucose by Beckman Synchron CX3 Analyser in the second (oGTT2) and by both methods in the third (oGTT3). In oGTT1, 1 subject was classified as diabetic and 15 as Impaired Glucose Tolerance (IGT). In oGTT3, using capillary blood glucose, 1 was diabetic, 8 IGT and 7 normal. Using venous whole blood, in oGTT2, 1 was diabetic, 3 IGT and 12 normal as compared to 1 diabetic, 4 IGT and 11 normal in oGTT3. There is considerable variation in classification as a result of using capillary blood glucose measured by reflectance meter as compared to the laboratory-based method. Capillary blood glucose measurement for oral glucose tolerance test cannot be recommended.

Case series of bronchoscopic removal of tracheobronchial foreign body in six adults.

Tracheobronchial foreign body is rare in adults. Diagnosis is difficult and requires a high index of suspicion. We report 6 cases of tracheobronchial foreign bodies in adults and their removal, as well as a literature review of this topic. Case records, chest radiographs and computed tomographies (CT) of the thorax were reviewed. There were 5 males and 1 female with a median age of 63.5 years. One patient could not protect his airway (tracheostomy). Foreign bodies were sutures (2), vegetable matter like peanuts, vegetables and popcorn (3), and a voice prosthesis. Main symptoms were cough, haemoptysis and breathlessness. There were few signs on physical examination and chest X-rays were not helpful in diagnosis. All patients had fibreoptic bronchoscopy although 3 subsequently required rigid bronchoscopy for foreign body removal. All foreign bodies were successfully removed without any complications.

Chylothorax: case report and review of literature.

Chylothorax is a relatively uncommon condition. We report a case of a 53-year-old Chinese man with chylothorax who presented with cough, breathlessness, loss of weight and generalised lymphadenopathy. He was initially diagnosed as having tuberculosis based on histology and cultures of the cervical lymph node. However, immunophenotyping of the pleural fluid by flow cytometry showed the presence of a monoclonal B cell population with Kappa light chain expression suggesting an underlying lymphoproliferative disorder. A repeat lymph node biopsy showed malignant lymphoma (follicular small cleaved type). In spite of aggressive measures which included bilateral tube thoracostomy drainage, a low fat diet, medium chain triglyceride diet, total parenteral nutrition, chemotherapy and mediastinal irradiation, his chylothorax persisted. Hence, we report a patient with persistent chylothorax and generalised lymphadenopathy who was subsequently diagnosed to have concurrent tuberculosis and malignant lymphoma. The literature on chylothorax is reviewed.

Clear cell carcinoma of the lung--a case report.

Clear cell carcinoma of the lung is a rare entity. We report the first case seen locally. The patient is symptomatic, presenting with a large pulmonary tumour. Histologically, there were clusters of large tumour cells with ample clear cytoplasm and absence of mucin, glandular and squamous differentiation. Urine analysis, blood carcinoembryonic antigen level and abdominal CT scan were normal.

Bronchoscopy in immunocompromised host with pulmonary infiltrates.

Pulmonary complications related to immunosuppression may be secondary to infection, neoplasia, toxic effects of chemotherapy and radiotherapy or the primary disease itself. The diagnostic yield from bronchoscopic studies on immunocompromised hosts (ICH) with pulmonary infiltrates varies widely and the indication and timing for bronchoscopic procedures remain uncertain. We prospectively studied 60 consecutive ICH with pulmonary lesions over a 12-month period. Bronchoscopic studies were performed as soon as pulmonary lesions were detected and within 72 hours of antimicrobial treatment. The patients were divided into two groups: E (40 patients) and L (20 patients) were bronchoscoped on average 1.6 days (SD 0.8) and 16.7 days (SD 10.8) respectively after clinical detection and antimicrobial treatment. A total of 131 bronchoscopic procedures were performed. These included bronchoalveolar lavage 60, bronchoscopic lung biopsy 47, bronchial biopsy 8, brushing 8 and washing 8. Diagnostic yields for bronchoscopically obtained fluid and tissue histology were 45% and 49% respectively. Both complement each other resulting in a higher diagnostic yield of about 70% of the patients in both groups. Procedural complications were minor (13% of cases) and mortality was zero. Infections accounted for approximately two-thirds of the pulmonary lesions. Patients bronchoscoped earlier received less antimicrobial empiric therapy and had shorter hospitalisation. Despite delayed bronchoscopy in ICH in the late group, bronchoscopic results influenced in 85% of patients. However, based on earlier use of appropriate therapy, shorter hospitalisation and decreased costs, we recommend early bronchoscopy when response to empiric treatment has been unsatisfactory.