Non-Infectious Lung Manifestations of Autoimmune Diseases in Cameroon

Autoimmune (AI) diseases are secondary to lack of tolerance against self antigens. They may have systemic or organ-specific manifestations. All lung structures can be affected. The aim of our study was to determinate clues of diagnosis and treatment facilities for noninfectious lung manifestations of AI disease.A multi-centre retrospective study was performed from January 2006 to July 2009 in Douala, Cameroon.Twenty-nine patients were included (59% female),with an average age of 42±10 (18­58) years. The lung was the discovery mode of AI disease in 79%. Systemic lupus erythematosus (SLE) was the most frequently observed AI disease (48%). Thirty-eight percent have at least one cure against pleural or smear-negative tuberculosis. Clinical anomalies found were: cough 79%, dyspnoea 69%, and crackles 41%. Morphological anomalies were interstitial lesions in 55% of chest Xrays,50% of ground grass pattern, and 25% of fibrosis on CT scan; chest function test showed restrictive pattern in 41%. Three (10%) patients were HIV positive with a CD4 cell count more than 500/mm³. Two patients underwent talc pleurodesis for recurrent pleural effusion. General steroids were prescribed to all patients, hydroxychloroquine to 31% and azathioprine to 21%. At the time of writing, 18 patients were still being followed up and 3 (10%) had died. AIs exist in many countries. Clues of diagnosis of non-infectious pulmonary involvement are a patient presenting with chronic respiratory symptoms, crackles at physical examination, negative sputum smear,and unusual chest X-ray abnormality for tuberculosis

Les leucémies lymphoides chroniques au CHU Yalgado Ouedraogo de Ouagadougou

20 cas de leucemie lymphoide chronique (LLC) ont ete diagnostiquees entre janvier 1995 et juin 2003 au Centre Hospitalier et Universitaire (CHU) Yalgado Ouedraogo de Ouagadougou au Burkina Faso. On y a compte 14 femmes et 6 hommes (doit deux femmes pour un homme) dont l'age moyen a ete de 53; 8 ans. Les patients ont chaque fois mis un long delai entre la survenue du premier symptome et la presentation a la consultation. Le motif de consultation le plus frequent a ete une masse abdominale en rapport a une splenomegalie associes ou non a des adenopathies. La lymphocytose sanguine en moyenne de 53.250/mm3 (extremes : 12;910-387.000/mm3) et l'anemie ont ete les perturbations biologiques essentielles. Sur les 20 observations; 16 etaient de mauvais pronostic car classees aux stades III et IV de Rai

Chronic obstructive pulmonary diseases in Thailand: incidence, prevalence, present status and future trends.

MATERIAL AND METHOD: Data on cases of COPD in 1999 were collected. RESULTS: [table in text] The mortality rate was 0.6-3.4 per cent in OPD cases and 11-17 per cent in IPD cases. The hospital stay was 2-90 days (mean 14 days). The cost per day in the ICU of government hospitals was Bht 7,000 and in private hospitals Bht 10,000.

Coarctation of the aorta in children at Siriraj Hospital.

A retrospective analysis of 33 children who were diagnosed to have coarctation of aorta at Siriraj Hospital between January 1989 and December 1998 was undertaken. There were 21 males (64%) and 12 females (36%). Their ages ranged from one day to 11 years (median 2 months). The majority of the patients (78.8%) were presented early within the first year of life. The predominant clinical manifestations were congestive heart failure (69.6%), systemic hypertension of the upper extremities (36.3%) and decreased femoral pulses. Chest roentgenogram revealed cardiomegaly (70%) and increased pulmonary blood flow (84%), reflecting congestive heart failure and associated left-to-right shunting. Electrocardiogram showed normal pattern (33.3%), right ventricular hypertrophy (33.3%), left ventricular hypertrophy (22.2%) and biventricular hypertrophy (11.2%). The younger the patient is, the more right ventricular predominance is demonstrated. According to the echocardiogram and/or aortogram, juxtaductal type was found in 51.5 per cent, postductal type in 27.3 per cent and preductal type in 21.2 per cent. Medical management included prostaglandin E1 infusion in a newborn baby presented with low-cardiac output state, anticongestion and antihypertension, if indicated, followed by surgical correction. The result of coarctectomy with end-to-end anastomosis with or without arch augmentation was good. The operative mortality rate was 5 per cent. The overall mortality in the present study was 9 per cent. The most common causes of death were multiorgan failure and pulmonary infection. Residual coarctation was found in 5 per cent.

Limitation of transthoracic echocardiography in the diagnosis of congenital heart diseases.

Nowadays, it has been widely accepted that echocardiography is the most efficient, non invasive diagnostic tool to diagnose congenital heart diseases. However, cardiac catheterization remains the gold standard to diagnose and obtain hemodynamic data prior to cardiovascular surgery. In order to find out the accuracy of transthoracic echocardiography in relation to the anatomical diagnosis of congenital heart diseases, 175 consecutive patients who underwent diagnostic cardiac catheterization during January 1999 to December 1999 were reviewed. All of them had complete echocardiographic studies prior to the procedure. The male to female ratio was 1.06:1. The median age at the time of echocardiography was 3.36 (0.01-28.8) years old. The indications of the cardiac catheterization were to demonstrate cardiovascular anatomy 64 per cent, to obtain pulmonary artery pressure and pulmonary vascular resistance 13.7 per cent, and to get both information 22.3 per cent. Tetralogy of Fallot (23.4%) was the most frequent cardiac malformation, followed by complex congenital heart diseases (22.3%), simple left to right shunt (12%), pulmonary atresia with ventricular septal defect (8.6%), tricuspid atresia (5.7%), simple d-transposition of great arteries (4%), etc. From cardiac catheterization; 49 cases (28%) revealed additional data which were surgically important, 3 cases (1.7%) resulted in different diagnoses, and 3 cases (1.7%) revealed additional information which was not surgically important. Inadequate imaging technique (36 cases, 65.5%) and limitation of technique (19 cases, 34.5%) were the reasons for missing anatomical findings of transthoracic echocardiography. Age at the time of echocardiography was not a significant factor affecting the accuracy. Persistent left superior vena cava, multiple aorto-pulmonary collateral arteries, pulmonary artery anatomy, and coronary artery anatomy were the most frequent cardiac lesions misdiagnosed by transthoracic echocardiography that were somewhat surgically important. The incorrect echocardiographic diagnoses were aorto-pulmonary window, patent ductus arteriosus, and vascular ring. Thorough and extensive echocardiographic scanning coupled with cooperative or adequately sedated patients by an experienced operator using an efficient echocardiographic machine might improve the accuracy of transthoracic echocardiography in the diagnosis of congenital heart diseases.

The Fontan operation: experience at Siriraj Hospital.

Seventy five patients underwent modified Fontan operation at Siriraj Hospital from October 1987 to December 1998. Cardiology data was analyzed retrospectively. Four patients' data was unavailable. Median age at operation was 9.7 (1.8-34) years old. Tricuspid atresia accounted for 38 per cent of the patients. Ten patients (14.1%) died in the acute post operative period due to consequence of low cardiac output. Another 3 patients (4.2%) expired in the intermediate and late post operative period. Age at operation, pulmonary artery size, pre-operative oxygen saturation, and mean pre-operative pulmonary artery pressure were not different between those who survived and those who died. Abnormal pulmonary vein, atrioventricular valve regurgitation, and underlying ventricular morphology statistically affected the acute survival of modified Fontan operation. Intraoperative aortic cross clamp time, and post operative mean pulmonary artery pressure on day 0, 1 and 2 post operation were found statistically shorter and lower in the survival group. Survival rate at 5 years was 83 per cent. Modified Fontan operation is the final palliative operation of choice for low risk single ventricle physiology in our institution with acceptable outcome. Thorough pre-operative hemodynamic and anatomic studies and staging modified Fontan procedure may include a higher number of candidates and improve the outcome of the operation.

Intermediate term follow-up on transcatheter closure of atrial septal defects by Amplatzer septal occluder.

BACKGROUND: Surgical repair of secundum atrial septal defect (ASD) is a safe, widely accepted procedure with negligible mortality. However, it is associated with morbidity, discomfort and a thoracotomy scar. As an alternative to surgery, a variety of devices for transcatheter closure of ASD have been developed. OBJECTIVES: We report our clinical experience with transcatheter closure of ASD using the Amplatzer Septal Occluder, a new occlusion device with intermediate term follow-up. PATIENTS & METHOD: Patients having ASD met established two-dimensional echocardiographic criteria for transcatheter closure were selected. ASD size was measured by transesophageal echocardiogram (TEE) and balloon occlusion catheter (stretched diameter). The Amplatzer's size was chosen to be equal to or 1 mm less than the stretched diameter. The device was advanced transvenously into a guiding sheath and deployed under fluoroscopic and TEE guidance. Once its position was optimal, it was released. TEE was undertaken to demonstrate the residual shunt. RESULTS: There were 26 patients with a mean age of 17.2 +/- 15.9 years old (2 to 60) and a mean weight of 22 +/- 37.5 kg. (10.7 to 62.5). The mean ASD diameter measured by TEE was 18.3 +/- 5.2 mm. and by stretched diameter was 22 +/- 7.5 mm. Four patients who had ASD stretched diameter over 32 mm were excluded because a larger device was not available. Devices were deployed in 22 patients with sizes from 9 to 30 mm (median = 22mm). Immediately after closure a tiny residual shunt was observed at the core of the device in each case. At 24 hours only two patients had a small (< 2 mm) shunt. One patient with fenestrated ASD had a device embolized into the right ventricle with successful removal and surgical closure. Patients were followed-up for a mean duration of 8 +/- 3.5 months (from 3 to 12 months). Complete occlusion was found in 20 out of 21 patients (95%). CONCLUSION: The Amplatzer Septal Occluder is a new device designed for closure of different sizes of ASD and can be easily and safely deployed. Our experience showed that this device could be used to close an ASD as large as 30 mm. The intermediate term follow-up also demonstrated an excellent closure result. Caution should be undertaken with patients who have a fenestrated atrial septal defect particularly at the septal rim.

Reference spirometric values for healthy lifetime nonsmokers in Thailand.

The normal spirometric reference values for Thai people are still not yet available. The aim of this study was to establish standard spirometric equations for Thai people. Subjects 10 years of age and over were selected and their demographic distributions represented that of the population of the whole country. Inclusion criteria were strictly lifetime nonsmokers, no history of chronic cardiopulmonary disease (using a modified ATS--DLD 78 respiratory adult questionnaire), normal standard chest radiograph and unremarkable physical examination. They had to be without respiratory symptoms at the time of the study. Spirometric values were obtained by 5 turbine system 'Pony graphic' (Cosmed, Italy) spirometers which met ATS recommendations. A normal group of 2299 women and 1655 men were selected. Regression analyses using sex, height and age as independent variables were used to provide equations for predicted values. The results were: [table: see text] FVC and FEV1 from this study are close to the Chinese but are 8-20 per cent lower than the Caucasians. These predicted equations are recommended to be used for future reference values in the Thai population.

Respiratory symptoms and pulmonary function of traffic policemen in Thonburi.

A cross-sectional study was conducted to assess whether traffic policemen working in Thonburi district of Bangkok had poorer respiratory health than the normal Thai population. The benefits of wearing masks as a preventative measure against the respiratory hazards of air pollution were assessed. Traffic policemen (n = 629) who had worked in Thonburi and male subjects (n = 303, the control group) were evaluated for respiratory symptoms using the British Medical Research Council questionnaire. Their pulmonary function was measured by spirometry. Only non-smokers were included in the final analysis and it was found that traffic policemen (n = 242) suffered significantly more cough or phlegm (18.6% vs 7.8%, P = 0.005) and more rhinitis symptoms (17.8% vs 7.8%, P = 0.009) than the control subjects (n = 129). The traffic policemen also had a significantly higher prevalence of abnormal air flow (FEV1 < 80% predicted) than the control group (21.1% vs 12.4%, P = 0.04). The mean values of FEV1 and FVC of the traffic policemen were significantly lower than the control group (3.29 +/- 0.5 L vs 3.43 +/- 0.5 L, P = 0.01 for FEV1 and 3.86 +/- 0.5 L vs 3.98 +/- 0.6 L, P = 0.047 for FVC). Traffic policemen who did not use protective masks had not only a significantly higher prevalence of abnormal FEV1 but also a significantly higher prevalence of abnormal FVC than the control group (35% vs 14%, P = 0.046). They also had higher relative risks of abnormal FEV1 (2.76 vs 1.63) and FVC (2.51 vs 1.23) than those who used protective masks. Multivariate analyses with controlling for age, height, and pack-years of cigarette smoking, revealed that the traffic policemen were significantly and independently associated with lower FEV1 and FVC. In conclusion, the traffic policemen who work in Thonburi have more cough and rhinitis symptoms and lower FEV1 and FVC than the normal Thai population. Traffic policemen who do not use protective masks have higher relative risks of abnormal FEV1 and FVC than those who use them.

Transcatheter laser-assisted balloon valvulotomy as primary treatment in newborn with pulmonary atresia and intact ventricular septum.

We report our initial experience and the first case in Thailand in successfully performing transcatheter laser perforation of membranous pulmonary valve and subsequent balloon dilations of the valve in a 14-day-old baby with pulmonary atresia and intact ventricular septum. After the procedure, right ventricular angiograms revealed anterograde flow across the pulmonary valve. There was no major complication. Doppler echocardiography one week later demonstrated a pressure gradient across the pulmonary valve of 30 mmHg and right ventricular systolic pressure of 60 mmHg. Her peripheral oxygen saturation improved from 70's immediately after the procedure to 92-97 per cent at one-month after the procedure.

Results of rapid two-stage arterial switch operation in patients with transposition of the great arteries: one-year postoperation.

The rapid two-stage arterial switch operation is an alternative therapy for patients with simple transposition of the great arteries who present beyond the neonatal period and have low left ventricular pressure. It provides normal ventricular function compared to the atrial switch operation. Between July 1994 and February 1997, there were 13 such infants who had rapid two-stage arterial switch operation performed at Siriraj Hospital. There was 1 late death (11 months after the operation). All 12 survivors (mean age 22.4 +/- 5.7 months) were clinically evaluated and had echocardiography performed at 14.8 +/- 4.9 months after the operation. All were asymptomatic. Echocardiogram revealed a residual small atrial septal defect (1 case), small ventricular septal defect (1 case), mild supravalvar neopulmonary stenosis (2 cases), bicuspid neoaortic valve without stenosis (2 cases), dilated neoaortic sinus of Valsalva (6 cases, 50%) and mild neoaortic insufficiency (11 cases, 91.7%). The left ventricular function was hyperdynamic after pulmonary artery banding and significantly decreased to normal level at the time of study (shortening fraction of 43.8 +/- 10.7 vs 29.2 +/- 3.8%, respectively, p = 0.0005). The wall thickness was significantly increased after pulmonary artery banding and decreased overtime (0.48 +/- 0.08 vs 0.32 +/- 0.05 cm, respectively, p < 0.0005). The left ventricular dimension was significantly increased both after pulmonary artery banding and at the time of study (2.06 +/- 0.42 vs 3.32 +/- 0.30 cm, respectively, p < 0.0005). The left ventricular mass was significantly increased after pulmonary artery banding and at the time of study (21.79 +/- 7.79 vs 33.08 +/- 7.40 g/m2, respectively, p = 0.0005). The mortality and morbidity of rapid two-stage arterial switch operation are low. However, long-term follow-up should be monitored.

Clonidine for smoking cessation.

Clonidine was used to reduce withdrawal symptoms of nicotine and increase the success rate of smoking cessation in the smoking cessation clinic of Siriraj Hospital. One hundred and fourteen subjects enrolled in a double-blind, randomised, placebo-controlled trial. Subjects were divided as clonidine group (n = 58) with the mean age of 38 years and placebo group (n = 56) with the mean age of 33 years. Both groups received information about harmful effects of smoking as well as behavioral modification protocol. The dose of clonidine used in this study was 300 micrograms and the duration of the trial was 5 weeks. Both subject groups attended the clinic weekly and received identical counselling. Clonidine did not reduce withdrawal symptoms of nicotine when compared to the placebo and the success rate of smoking cessation at the end of the 5 weeks' period was identical between the two groups (clonidine 50%; placebo 48%, p > 0.05). No significant side effects of clonidine were found. There was no correlation between background educational level, income, amount of cigarettes smoked per day and the success rate in both groups. In conclusion, clonidine did not show any beneficial effect on smoking cessation.

Percutaneous balloon pulmonary valvuloplasty in children: experience at Siriraj Hospital.

Twenty-seven children with pulmonary valvar stenosis with pressure gradient (PG) > or = 40 mmHg underwent percutaneous balloon pulmonary valvuloplasty (PBPV) at Siriraj Hospital between February 1993 and August 1996. There were 13 males and 14 females, with an age range from 2 months to 14 years, and body weight from 4.7 to 42.1 kg. The majority (92.6%) were asymptomatic. Before the PBPV, the pulmonary valve annulus (PVA) measured by echocardiography was significantly greater than that measured by cardiac catheterization (15.2 +/- 3.7 vs 14.5 +/- 3.9 mm, P = 0.006). However, there was linear association (r = 0.972) between the two methods. The PG obtained by the two methods showed no significant difference (90.8 +/- 35.3 by echocardiography vs 97.3 +/- 47.2 mmHg by catheterization, P = 0.266). Immediately after PBPV, the right ventricular systolic pressure (113.7 +/- 41.1 pre vs 62.3 +/- 28.1 mmHg post) and the PG 103.4 +/- 43.4 pre vs 49.0 +/- 31.1 mmHg post) were significantly reduced (p < or = 0.0005). At 6-mo follow-up echocardiography, the PG was 28.6 +/- 17.6 mmHg and was significantly reduced (P = 0.0005). The PVA significantly increased at the 12 mo follow-up (15.2 +/- 3.6 pre vs 17.6 +/- 3.8 mm post, P = 0.001). Only minor complications were reported in the present study; bleeding (3.7%), transient bradycardia (7.4%) and pulmonary regurgitation not more than moderate severity (79%). The immediate and intermediate results of PBPV are excellent with a success rate of 85 per cent.

Successful transcatheter coil embolizations of complex pulmonary arteriovenous fistulas: the first case in Thailand.

Successful transcatheter coil embolizations of the left lower lobe pulmonary arteriovenous fistulas, the first case in Thailand, in a 6-year-old boy presenting with increased cyanosis was reported. Transcatheter management of unusual sites of right-to-left intrapulmonary shunting can provide gratifying clinical improvement in some children.

Percutaneous coil embolization and balloon-expandable stenting; new treatments in intractable cardiac failure after Fontan procedure: a case report.

Successful percutaneous coil embolization of aortopulmonary collaterals and balloon-expandable stent implantation of left pulmonary artery stenosis in a child with hypoplastic right heart syndrome were reported, Presently, interventional cardiac catheterization is a very useful treatment strategy in congenital heart diseases unamenable to or inaccessible for surgery.

Dissertation of reported cases of nontuberculous mycobacteriosis in Thailand.

During the period from 1967 to 1988, there were 10 published reports of 44 patients from whom mycobacteria other than tubercle bacilli had been isolated clinic specimens. This communication presents results of a scrupulous review of each of the papers which revealed that some of the patients cited in the reports did not meet with the criteria for diagnosis, and some of the cases might have been the same patients as those documented by different investigators.

Treatment of community-acquired pneumonia with ofloxacin.

Our study of 28 carefully selected patients proved that ofloxacin is a safe and effective drug for mild to moderately severe community-acquired pneumonia. An effective oral antimicrobial drug such as ofloxacin can be used as an alternative to conventional therapy in community-acquired pneumonia.

Clinico-physiological status of Thai COPD patients.

We examined the relationships between certain clinical and physiological data from 56 patients with chronic obstructive pulmonary disease, and have formulated 15 relevant equations from which various respiratory indices can be estimated. Multiple linear regressions thus obtained evidently suggest that airway resistance and ventilatory drive are the main factors in the control of breathing among Thai COPD subjects; the exercise tolerance test showed some correlation with airflow obstruction and with respiratory muscle strength. Clinical implementation of certain findings has been outlined.

Experiences from a one-year supervision of pulmonary tuberculosis patient and Their associates.

Monthly scheduled follow-ups of 28 sputum-smear-culture-positive tuberculosis patients and 110 members of their families revealed 14 suspected cases of pulmonary tuberculosis and several interesting findings: (1) the incidence of tuberculosis was mostly among poor families with unsuitable shelter; (2) assessing family members and close associates of patients proved to be a fruitful approach for case-finding; (3) several BCG-vaccinated persons were found to have developed tuberculosis; (4) despite enthusiastic supervision of patients undergoing treatment, the defaulter rate was high (19.5%); and (5) all the antituberculotic regimens prescribed in this paper proved effective, as indicated by negative sputum examination from the fourth month of therapy onwards and a relapse rate of only 3.0 percent. Suggestions are made for improving the control of tuberculosis among the general public.

Smoking among Thai medical students.

This survey was conducted as part of “The World-wide Epidemiological Study on the Behaviour and Attitudes of Medical Students Towards Tobacco Consumption and Its Prevention” in collaboration with the Committee on Smoking and Health of the International Union Against Tuberculosis and Respiratory Diseases. The primary purpose of the study was to obtain base-line data of the students’ habits, knowledge and attitudes towards smoking for comparison with results of the annual follow-up study until graduation. It was also hoped that interest of students as well as their teachers would be aroused by promoting concrete decisions and incentives to fight against tobacco consumption. From questionaires handed out to 132 first-and 143 fifth-year medical students of Mahidol University Faculty of Medicine Siriraj Hospital at the beginning of their first academic semester, the responses disclosed that there were only 2.1% who smoked daily for 6 months or longer in the 5th -year class while there was none in the 1st -year class. Most of the students in both classes have pledged themselves against smoking in order to maintain their own health and to set good examples for patients and youngsters. Eighty-nine per cent of the students knew of the hazard of smoking, particularly as a definite cause of lung cancer, chronic bronchitis, chronic pulmonary emphysema, and as a precipitating cause of coronary heart disease. Twenty-five to 30% of students said they will advise patients against smoking even if they have no smoking-related disease and have not raised the question of smoking. Most of the students agreed upon the responsibility of doctors to convince people to quit smoking, but they expected little satisfactory outcome. In their opinion the fruitful ways to reduce smoking through legislative action were by prohibition of selling tobacco to children, restriction of smoking in closed public places and provision of special smoking areas in hospital. There were few unremarkable discrepancies of findings in behaviour and attitudes towards smoking between the two groups of medical students.