Personalised management of Chronic Obstructive Pulmonary Disease (COPD): Malaysian consensus algorithm for appropriate use of inhaled corticosteroid (ICS) in COPD patients

@#Background: Regarding the long-term safety issues with the use of inhaled corticosteroids (ICS) and the clinical predominance of dual bronchodilators in enhancing treatment outcomes in chronic obstructive pulmonary disease (COPD), ICS is no longer a “preferred therapy” according to the Global Initiative for Chronic Obstructive Lung Disease except on top of a dual bronchodilator. This has necessitated a change in the current therapy for many COPD patients. Objective: To determine a standardised algorithm to reassess and personalise the treatment COPD patients based on the available evidence. Methods: A consensus statement was agreed upon by a panel of pulmonologists in from 11 institutes in Malaysia whose members formed this consensus group. Results: According to the consensus, which was unanimously adopted, all COPD patients who are currently receiving an ICS-based treatment should be reassessed based on the presence of co-existence of asthma or high eosinophil counts and frequency of moderate or severe exacerbations in the previous 12 months. When that the patients meet any of the aforementioned criteria, then the patient can continue taking ICS-based therapy. However, if the patients do not meet the criteria, then the treatment of patients need to be personalised based on whether the patient is currently receiving long-acting beta-agonists (LABA)/ICS or triple therapy. Conclusion: A flowchart of the consensus providing a guidance to Malaysian clinicians was elucidated based on evidences and international guidelines that identifies the right patients who should receive inhaled corticosteroids and enable to switch non ICS based therapies in patients less likely to benefit from such treatments.

Management of asthma in adults in primary care

@#Asthma is a chronic inflammatory disease of the airway which is often misdiagnosed and undertreated. Early diagnosis and vigilant asthma control are crucial to preventing permanent airway damage, improving quality of life and reducing healthcare burdens. The key approaches to asthma management should include patient empowerment through health education and selfmanagement and, an effective patient-healthcare provider partnership.

Assessing Airflow Limitation among Smokers in a Primary Care Setting

Background: Many smokers have undiagnosed chronic obstructive pulmonary disease(COPD), and yet screening for COPD is not recommended. Smokers who know that they haveairflow limitation are more likely to quit smoking. This study aims to identify the prevalence andpredictors of airflow limitation among smokers in primary care.Methods: Current smokers ≥ 40 years old who were asymptomatic clinic attendees in aprimary care setting were recruited consecutively for two months. We used a two-step strategy.Step 1: participants filled in a questionnaire. Step 2: Assessment of airflow limitation using apocket spirometer. Multiple logistic regression was utilised to determine the best risk predictorsfor airflow limitation.Results: Three hundred participants were recruited. Mean age was 58.35 (SD 10.30) yearsold and mean smoking history was 34.56 pack-years (SD 25.23). One in two smokers were found tohave airflow limitation; the predictors were Indian ethnicity, prolonged smoking pack-year historyand Lung Function Questionnaire score ≤ 18. Readiness to quit smoking and the awareness ofCOPD were low.Conclusions: The high prevalence of airflow limitation and low readiness to quit smokingimply urgency with helping smokers to quit smoking. Identifying airflow limitation as an additionalmotivator for smoking cessation intervention may be considered. A two-step case-finding methodis potentially feasible.

Frequency and contributing factors for acute pancreatitis after endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice

Objective: To evaluate the frequency and contributing factors for acute pancreatitis after endoscopic retrograde cholangio-pancreatography in patients with obstructive jaundice. Study Design: Descriptive case series. Place and Duration of Study: A descriptive case series conducted at department of Gastroenterology, Shaikh Zayed Hospital, Lahore in the period of six months

Material and Methods: Two hundred and thirty patients diagnosed as having obstructive jaundice and undergoing ERCP who fulfilled the inclusion criteria were included in the study from the outpatient and indoor department of Gastroenterology-Hepatology Shaikh Zayed Hospital Lahore. Informed consent was taken. After the selection of the cases, patients were evaluated for the presence or absence of contributing factors like age, gender, cannulation attempts, cannulation time, percutaneous papillotomy, pancreatic duct contrast injection and previous history of post ERCP pancreatitis. Data was analysed by using the statistical software for social sciences [SPSS] version 15

Results: In our study, mean age was 44 +/- 14.12 years. Out of 230 patients 42.17% [n=97] were male and 57.83% [n=133] were females. Frequency of acute pancreatitis after ERCP in patients with obstructive jaundice was 4.78% [n=11] while 95.22% [n=219] had no findings of acute pancreatitis after ERCP. Frequency of factors for acute pancreatitis after endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice was recorded which shows that out of 11 cases, 45.45% [n=5] were females, 36.36% [n=4] had previous history of Post ERCP Pancreatitis, 27.27% [n=3] had >5 attempts of cannulation, 36.36% [n=4] had >5 minute time for cannulation, 54.55% [n=6] had pre-cut papillotomy while 63.64% [n=7] had pancreatic duct contrast injection

Conclusion: We concluded that frequency of acute pancreatitis after endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice was found not very high in our practice. Female gender, precut papillotomy and pancreatic duct contrast injection were the most important risk factors for the development of acute pancreatitis

A Pilot Randomized Control Cross over Study Evaluating the Effectiveness and Safety of Mechanical Percussor Compared with Conventional Chest Physiotherapy in Adults with Productive Cough

Introduction: Conventional Chest Physiotherapy (CCPT) remains the mainstay of treatment for sputum mobilization in patients with productive cough such as bronchiectasis and “Chronic Obstructive Airway Disease” (COPD). However CCPT is time consuming requires the assistance of a physiotherapist and limits the independence of the patient. Mechanical percussors which are electrical devices used to provide percussion to the external chest wall might provide autonomy and greater compliance. We compared safety and efficacy of a mechanical chest percusser devised by Formedic Technology with conventional chest percussion. Methods: Twenty patients (mean age 64years) were randomly assigned to receive either CCPT or mechanical percussor on the first day and crossed over by “Latin square randomisation” to alternative treatment for 6 consecutive days and the amount of sputum expectorated was compared by dry and wet weight. Adverse events and willingness to use was assessed by a home diary and a questionnaire. Results: There were 13 males and 7 females, eight diagnosed as bronchiectasis and 12 COPD. The mean dry weight of sputum induced by CCPT (0.54g + 0.32) was significantly more compared with MP (0.40g + 0.11); p-value = 0.002. The mean wet weight of sputum with CCPT (10.71g + 8.70) was also significantly more compared with MP (5.99g + 4.5); p-value < 0.001. There were no significant difference in adverse events and majority of patients were willing to use the device by themselves. Conclusion: The mechanical percussor although produces less sputum is well tolerated and can be a useful adjunct to CCPT

Myocardial ischaemia and reperfusion injury: reactive oxygen species and the role of neutrophil

A growing body of evidence suggests that oxygen radicals can mediate myocardial tissue injury during ischaemia and, in particular, during reperfusion. This review focuses on the role of neutrophil as a mediator of myocardial damage. Upon reperfusion, neutrophils accumulate and produce an inflammatory response in the myocardium that is responsible, in part, for the extension of tissue injury associated with reperfusion. It has shown that the inhibition of neutrophil accumulation and adhesion is associated with decreased infarct size. This strongly suggests that myocardial cells at risk region undergo irreversible changes upon reperfusion and accumulation of neutrophils. Several pharmacological agents [ibuprofen, allopurinol, prostacyclin, and prostaglandin E analogues] protect the myocardium from reperfusion injury. In addition, the mechanisms by which these agents act and directions of research that may lead to therapeutically useful approaches are also discussed in this review

Deafness in highlanders.

Hearing impairment is a common health problem throughout the world. Over two million human beings on the earth are either deaf or hearing impaired, most of them in the developing countries. Pakistan is a land of multiethnic, multiracial, multilingual and varied anthropological cultures and populations. A substantial number of children and adults are suffering from hearing impairment, mostly provoked by poverty and lack of health facilities. This non-interventional descriptive study was carried out while providing primary ear care and conducting an epidemiological survey in the Northern territories of Baltistan, that covers a large terrain of Himalayan mountains of the Hindukush and Korakoram Range. A total of 1964 patients were examined during 7 camps conducted by IMPACT Pakistan in 1998, out of which 1160 were females and 804 were males. Short history was recorded and meticulous ear examination was performed, which includes otoscopy withpneumatic attachment and tuning fork testing. Tympanometry was performed in selected cases of glue ears having clinical evidence of effusion behind the drum. Common causes of deafness and hearing impairment were drawn from this study. Glue ear was found in 503 patients [25.61%] out of which 353 patients-were selected for tympanometry Impacted hard wax was found in 402 patients [20.46%]. Chronic suppurative otitis media [C.S.O.M] was found in 307 patients [15.61%] with discharging perforations in 178 patients [57.98%], dry perforations in 111 patients [36.15%] and cholesteatoma in 18 patients [5.86%]. Tympanosclerotic patches were found in 231 patients [11.76%]. Sensorineural hearing loss [SNHL] was found in 225 patients [11.43%], majority of them were due to aging process [presbaycusis] in 97 cases [43.11%]. Post-infectious neural loss was found in 55 cases [24.44%]. 39 cases [17.33%] of SNHL were associated with goitre and 7 cases [3.11%] of syndrome associated hearing loss were identified. The final message is that all the causes seen in mountainous areas of Northern territories, as indeed elsewhere in Pakistan are preventable. All we need is public awareness, which can be achieved through the help of the international agencies, particularly the W.H.O.