Clinical characteristics, management in real world practice and long-term survival among COPD patients of Northern Thailand COPD club members.

OBJECTIVE: To assess the baseline clinical characteristics, management, and long-term survival of hospital-based COPD patients in the northern part of Thailand. MATERIAL AND METHOD: One hundred and ninety five hospital-based COPD patients from community and provincial hospitals in the northern part of Thailand were recruited between May and November 2002. They were followed up for 45 months for survival. RESULTS: Most of them (71.3%) were in the advanced stage and 41.8% were undernourished. Only a small fraction of the advanced stage patients (25.7%) estimated their dyspnea severity correctly with the disease stages. The frequency of the exacerbations increases as the disease become more severe. Only 23.7% of the advanced stage patients had received regular bronchodilator therapy. No patients had received pulmonary rehabilitation and long-term oxygen therapy. The 45 months survival was 75.6% in all patients. The severe group with low BMI had significantly lower survival than the one with normal BMI (67.7% vs. 89.8%, p = 0.040). CONCLUSION: Most COPD patients in the northern part of Thailand were in the advanced stage. They were commonly undernourished and exacerbated but still under treated according to standard treatment guidelines. BMI tends to influence the long-term survival of the advanced stage patients.

A 12-case series of Penicillium marneffei pneumonia.

BACKGROUND: Penicillium marneffei, an endemic fungus in Southeast Asia and southern China, is the cause of opportunistic infection in HIV-infected patients who may present with symptoms and signs of the lungs, and abnormal chest radiographs. However, only a few cases of pulmonary infection from this organism have been reported. OBJECTIVE: To study the clinical manifestations of patients with Penicillium marneffei pneumonia diagnosed by sputum or bronchoalveolar lavage (BAL) fluid culture MATERIAL AND METHOD: Retrospective descriptive study of patients who were diagnosed with Penicillium marneffei pneumonia at Maharaj Nakorn Chiang Mai Hospital from September 1999 to July 2004. RESULTS: Twelve patients (eight males, four females) were included with mean age of 36.1 years. Nine cases were HIV-infected. Their presenting symptoms included fever, cough, dyspnea and weight loss. Skin lesions, hepatomegaly and lymphadenopathy were extrapulmonary signs. Chest radiographs revealed diffuse reticulonodular, diffuse reticular, localized alveolar, localized reticular infiltration, and cavitary lesion. The diagnosis was made by cultures from the sputum in five cases and BAL fluid in the others. Co-infections with Streptococcus pneumoniae, Klebsiella pneumoniae, Mycobacterium tuberculosis, Cryptococcus neoformans, and Strongyloides stercoralis were found. Most of them were treated by intravenous amphotericin B followed by oral itraconazole, or oral itraconazole. CONCLUSION: Penicillium marneffei pneumonia has non-specific clinical manifestations, it cannot be excluded from other infections and may have co-infections. Physicians should include this infection in their differential diagnosis especially in immunocompromised patients.

Lung cancer in Maharaj Nakorn Chiang Mai Hospital: comparison of the clinical manifestations between the young and old age groups.

OBJECTIVES: To examine and compare the clinical manifestations of lung cancer between the age groups of 40 years or less and over 40 years at Maharaj Nakorn Chiang Mai Hospital from January 2002 - December 2003. MATERIAL AND METHOD: Six hundred and nineteen patients with confirmed pathological cell type lung cancer were newly registered. RESULTS: The mean age was 60.1 years and male to female ratio 1.79:1. Their smoking history was presented in 72% of patients, with cough being the most common symptom followed by weight loss, dyspnea, chest pain, and hemoptysis with a median duration of 2 months. Mass or nodule was the most common radiographic finding, and adenocarcinoma was the most common pathological cell type. Most of the patients (82.4%) presented in the advanced stage. There were 19 patients (3.1%) aged equal to 40 years or less. In this group, chest pain and adenocarcinoma were presented more significantly, while a smoking history was found to be less significant in females. The duration of symptoms in this group tended to be shorter (1.3 months), but not statistically significant. More than 80% of both patient groups presented in the advanced stage. CONCLUSION: Lung cancer in the young is uncommon, but most clinical manifestations are not different from older patients. The less significant smoking history, especially in females, tendency of shorter duration of symptoms, and more frequent adenocarcinoma in the younger patients may have some factors that are associated and should be studied further.

Efficacy of weaning protocol in medical intensive care unit of tertiary care center.

OBJECTIVE: To evaluate the efficacy of the protocol-directed weaning from a mechanical ventilator compared to physician-directed weaning. MATERIAL AND METHOD: A comparative study between retrospective studies of physician-directed weaning as controls (N = 198) reviewed from July 2000 to July 2002 and the prospective studies of protocol-directed weaning as intervention (N = 196) enrolled from October 2002 to October 2003 in the medical ICU of Maharaj Nakorn Chiang Mai Hospital, tertiary care center of northern Thailand. Study results were concluded by Fisher's exact test. RESULTS: Baseline characteristics data of both groups including sex, age, illness severity which demonstrated by APACHE II score and PaO2/FiO2 ratio, causes of respiratory failure and mode of mechanical ventilation used were similar. The duration of mechanical ventilation before weaning was 5.89 +/- 3.71 days in the protocol-directed group and 7.41 +/- 5.54 days in the physician-directed group (p < 0.05). Weaning duration in the protocol-directed group was significantly shorter than the physician-directed group (14.58 +/- 16. 98 hours VS 47.09 +/- 38.23 hours; p < 0.05). Kaplan-Meire analysis demonstrated that patients in the protocol-directed group had significantly shorter durations of mechanical ventilation compared to patients in the physician-directed group (p = 0.001, log-rank test). The ICU LOS was significantly shorter in the protocol-directed group (7.91 +/- 4.71 vs 11.53 +/- 7.80 days; p < 0.05). The 28 days mortality rate and the incidence of hospital acquired pneumonia seemed to be less in the protocol-directed group (4.60% vs 6.10% and 5.60% vs 10.10% consecutively) and reintubation rate seemed to be higher in the protocol-directed group (6.1% vs 4.5%) than the physician-directed group but differences were not significant (p > 0. 05). CONCLUSION: Protocol-directed weaning proved to have more efficacy in weaning patients from a ventilator than physician-directed weaning in terms of weaning duration and ICU length of stay without a deteriorating effect to the patients.

Role of bronchial washing in the diagnosis of endoscopically visible lung cancer.

OBJECTIVE: To evaluate the usefulness of bronchial washings in addition to endobronchial biopsies and/or bronchial brushings for the pathological diagnosis of endoscopically visible lung cancer. MATERIAL AND METHOD: A retrospective study of patients diagnosed as lung cancer by bronchoscopy between January 1995 and December 1998. Patients were included in the study if they had 1) endoscopically visible tumors (exophytic mass or irregular mucosa) and 2) bronchial washings (BWs) performed together with either endobronchial biopsies (EBBs) or bronchial brushings (BRs). Patients were classified into 3 groups according to the result of the histocytology as follows: A) positive in both BWs and EBBs/BRs, B) positive in only EBBs/BRs and C) positive in only BWs. A number of patients in each group were analyzed to see the benefit of BWs as an add-on diagnostic tool. The authors also evaluated the benefits of BWs in the subgroup of patients who had necrotic and bleeding tumor Statistical analysis of the data was performed by using the likelihood-ratio chi-square test. RESULTS: Two hundred and twenty-two patients were included in the present study. The number of patients in group A, B and C was 108, 108, and 6, respectively. Therefore, BW was the only diagnostic procedure in 6 patients (2.7%). Those 6 patients all had incurable non-small cell lung cancer The likelihood of a positive BWs in an exophytic mass was no different from irregular mucosa. The likelihood of a positive BWs in a tumor with necrosis was higher than in a tumor without necrosis. In contrast, tumors with active bleeding had a lower likelihood of positive BWs when compared with those without bleeding. The likelihood ratio showed no statistical significance in any of the groups. CONCLUSION: The addition of BWs to either EBBs or BRs is beneficial, but it may not be cost-effective. This procedure may be useful in patients with an endoscopically visible necrotic tumor In contrast, the bronchoscopic finding of a bleeding tumor may be a negative predictor. This procedure may be a suitable approach when performed only in selected cases, such as necrotic tumor or negative initial EBBs/BRs.

Pulmonary rhodococcosis an unrecognized pulmonary infection in AIDS patients.

Pulmonary rhodococcosis is an uncommon pulmonary infection in human beings, but the case reports have been increasing in HIV-infected patients. We report a female AIDS patient presenting with fever, productive cough and weight loss over 6 weeks. Chest x-ray showed a cavitary lesion with air fluid level in the right upper lobe infiltration. Sputa for AFB stain were negative for 3 consecutive days. Fiberoptic bronchoscopy was performed and bronchoalveolar lavage fluid was examined. It showed a gram-positive, weakly acid-fast coccobacilli. The culture grew only Rhodococcus equi. She was treated with erythromycin and rifampin and responded well.