Compliance with continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea among privately paying patients- a cross sectional study.

BACKGROUND: To evaluate the compliance, benefits and side effects associated with continuous positive airway pressure (CPAP) therapy among Pakistani patients treated for obstructive sleep apnea (OSA) in private sector. METHODS: Patients diagnosed to have OSA based on overnight study who were recommended for CPAP therapy, between 1998 and 2003, were evaluated by telephonic survey and review of hospital notes. Compliance, benefits and side effects associated with CPAP therapy were assessed. RESULTS: Out of 135 patients who were prescribed CPAP therapy, 75 could be contacted. Sixty (80%) started using CPAP within one month of diagnosis and 46 (61%) continued to use it long-term (beyond one year). Compliance with CPAP therapy was associated with higher body mass index, higher Epworth sleepiness scale score, history of witnessed apnea, and reduction in daytime sleepiness with CPAP therapy. OSA severity as assessed by apnea-hypopnea index did not affect compliance with CPAP therapy. Use of anti-depressants and CPAP induced sleep disturbances were associated with poor compliance with CPAP therapy. CONCLUSIONS: Obesity, excessive daytime sleepiness, witnessed apnea and improvement of daytime symptoms following use of CPAP were predictors of improved compliance. Use of antidepressants and CPAP induced sleep disturbances were predictors of poor compliance.

Pulmonary functions in patients with diabetes mellitus.

BACKGROUND: A reduction in lung capacity has been reported previously among diabetics. According to WHO estimates, Pakistan is currently eighth in the prevalence of diabetes mellitus (DM) and will become fourth by the year 2025 with over 15 million individuals. This study was designed to see the impairment of lung functions on spirometry in DM patients. OBJECTIVE: Our aim was to investigate the pulmonary functions tests of Pakistani patients with DM. MATERIALS AND METHODS: Between January to July 2004, 128 subjects who were never-smokers and had no acute or chronic pulmonary disease were recruited. Sixty-four of these subjects had DM and 64 were healthy matched controls. All underwent screening with detailed history, anthropometry, lipid profile, and spirometric measurements at the Aga Khan University Hospital, Karachi, Pakistan. RESULTS: The mean age of diabetics and matched control were 54.3±9 and 54.0±8 (P<0.87) years, respectively. Diabetes patients showed a significant reduction in the forced vital capacity (FVC) [mean difference (95% CI) - 0.36 (-0.64, -0.07) P<0.01], forced expiratory volume in one second (FEV(1)) [- 0.25(-0.50, -0.003) P<0.04], and slow vital capacity (SVC) [- 0.28(-0.54, -0.01) P<0.04], relative to nondiabetic controls. There was no significant difference noted in the forced expiratory ratio and maximum mid-expiratory flow between the groups. There was also a significant higher level of triglycerides noted among diabetics (P<0.001). CONCLUSION: Diabetic patients showed impaired lung function independent of smoking. This reduced lung function is likely to be a chronic complication of diabetes mellitus.

Association of self-reported nasal blockage with sleep-disordered breathing and excessive daytime sleepiness in Pakistani employed adults.

PURPOSE: To assess prevalence of self-reported nasal congestion and its association with sleep-disordered breathing (SDB) and excessive daytime sleepiness (EDS) in Pakistani adults employed at a medical university. METHODS: All full-time employees of a medical university (n=3,470) were delivered a questionnaire that elicited demographic data, symptoms of nasal blockage and SDB and Epworth Sleepiness Scale score. Overnight pulse oximetry was performed on self-reported snorers and a random sample of non-snorers. Supervised polysomnography was performed on subjects with oxygen desaturation index >5/h. Logistic regression analysis was used to assess the association of nasal blockage with SDB and EDS. RESULTS: Of 2,497 (72%) responders, 45.2% reported nasal congestion. Self-reported nasal blockage was significantly associated with an increased risk of SDB symptoms: snoring (odds ratio [OR] 1.9), witnessed apnoea (OR, 2.2) and unrefreshing sleep (OR, 1.7). Those with nasal blockage had higher Epworth Sleepiness Scale score (5.5 ± 3.6 vs. 3.9 ± 3.3, p<0.001) compared with those without nasal blockage. Nasal blockage was associated with increased risk of doziness in seven out of eight items of Epworth Sleepiness Scale score. Oxygen desaturation index and apnoea-hypopnoea index were similar between subjects with and without self-reported nasal blockage. CONCLUSION: Self-reported nasal blockage is a common symptom in employed Pakistani adults. Self-reported nasal blockage is significantly associated with symptoms of SDB and EDS but not with respiratory variables on overnight sleep monitoring.

Prevalence and associated risk factors of sleep-disordered breathing symptoms in young and middle-aged Pakistani employed adults.

PURPOSE: The objective of this study was to evaluate the prevalence of self-reported sleep-disordered breathing (SDB symptoms and its associated risk factors in Pakistani employed adults. METHODS: Full-time employees (n = 3470) of a medical university were evaluated. Self-administered questionnaire elicited information about demographic data, symptoms of SDB, smoking and alcohol use, presence of nasal congestion, family history of snoring, and included the Epworth Sleepiness Scale. Prevalence of self-reported snoring and of combined SDB symptoms (snoring plus at least one other SDB symptom) was evaluated. Regression analyses were used to assess risk factors associated with self-reported snoring and combined SDB symptoms. RESULTS: Among the 2,497 (72%) responders, prevalence of self-reported snoring was 32%, and combined SDB symptoms 25%. A higher prevalence of snoring and combined SDB symptoms in male gender diminished with age. In univariate analysis, the odds of snoring was higher with age >or=35 yrs (odds ratio (OR) 2.6, confidence interval (CI) 2.2-3.2), body mass index >or=23 (OR 2.6, CI 2.2-3.1), and collar size above 40 cm (OR 2.7, CI 2.3-3.3). Self-reported nasal blockage (OR 1.9, CI 1.6-2.2) and family history of snoring (OR 2.9, 2.5-3.5) were other risk factors. In logistic regression analysis, significant risk factors for SDB symptoms were age, body mass index, collar size, nasal blockage, and family history of snoring. Male gender, smoking and alcohol were not significant risk factors for SDB symptoms. CONCLUSION: The prevalence of SDB symptoms in Pakistani employed adults was comparable to Western populations. However, male gender and smoking were not significant risk factors for SDB symptoms.

Community acquired pneumonia: risk factors associated with mortality in a tertiary care hospitalized patients.

OBJECTIVE: To evaluate risk factors associated with mortality in patients hospitalized with CommunityAcquired Pneumonia (CAP) from a developing country. METHODS: An observational study was conducted on adult patients admitted with a diagnosis of CAP from January 2002 to August 2003 at Aga Khan University hospital, Karachi, Pakistan. Clinical records were reviewed for demographic characteristics, clinical and laboratory features, hospital course, and risk factors associated with mortality. RESULTS: A total of 329 patients (187 males) were admitted with CAP. Two-third of patients had underlying co-morbid medical illnesses. Complications developed in 15.7% cases and the overall mortality rate was 11%. Risk factors were identified on initial clinical assessment, laboratory and radiological features and during hospital course. On admission elevated blood urea, new onset of confusion, abnormal liver function test, low serum albumin, cardiomegaly and presence of underlying malignancy were strongly associated with increased mortality. Failure to respond to therapy was associated with a high risk of mortality as depicted by complication during hospital stay (Odds Ratio = 23.3, 95% Confidence Interval = 10.3-52.8), need for mechanical ventilation (OR = 17.1, 95% CI = 7.4-39.8) and need for intensive care unit (OR = 9, 95% CI = 4.2-19.3). CONCLUSIONS: Abnormal liver function test, low albumin and presence of cardiomegaly were more significant mortality risk factors than age, respiratory rate and blood pressure. Elevated blood urea and confusion remain strong risk factors on admission. Failure of response to therapy and onset of complications heralded a high risk of death.

Drug susceptibility pattern of Mycobacterium tuberculosis in adult patients with miliary tuberculosis.

Miliary tuberculosis (TB) is a fatal form of TB. Although drug resistance in TB patients has increased worldwide, there is limited information on drug resistance in miliary TB. This study from Pakistan evaluated drug susceptibility pattern among miliary TB patients of a high TB-burden country. All adult patients with miliary TB, admitted between 1994 and 2001, were identified using a computerized database. Culture-positive isolates were evaluated for drug susceptibility using middle brook 7H10 agar according to National Committee for Clinical Laboratories Standard criteria. Of 110 patients diagnosed with miliary TB, 32 (30%) were culture positive (yielding 35 culture isolates). The sources of positive cultures were sputum (37%), cerebrospinal fluid (18%), lymph nodes (12%), bone marrow (9%), bronchial wash (9%), urine (6%), lungs (6%) and liver (3%). Isoniazid resistance was found in three (9%) isolates. All the isolates were sensitive to rifampicin, ethambutol, pyrazinamide and streptomycin. Despite a worldwide increase in TB drug resistance, patients with miliary TB have infection with drug-sensitive mycobacterium. First-line anti-TB drugs should be used as initial therapy in miliary TB patients.

Knowledge, attitude and misconceptions regarding tuberculosis in Pakistani patients.

OBJECTIVE: To assess knowledge of patients with tuberculosis; about their disease and misconceptions regarding TB. METHODS: A cross sectional study was conducted at Out-patient clinics of two teaching hospitals (private and public) in Karachi, Pakistan. A questionnaire was filled for the purpose. RESULTS: A total of 170 patients were interviewed, 112 from private and 58 from a public sector hospital. Cough, fever, bloody sputum and chest pain were recognized as the common symptoms of TB. Eleven (7%) patients thought TB was not an infectious disease and 18 (10.6%) did not consider it a preventable disease. Contaminated food was considered the source of infection by 81 (47.6%) and 96 (57%) considered emotional trauma/stress the causative agent of TB. No counseling about preventing spread was received by 81 (50%) patients and 97 (57%) considered separating dishes as an important means of preventing spread. Thirty one (18%) patients would have discontinued their medications following relief of symptoms. Thirty nine (23%) of the respondents thought that TB could lead to infertility and 66 (38.8%) believed that there were reduced chances of getting married following infection. CONCLUSION: Misconceptions concerning TB are common in Pakistani patients. Lack of knowledge on Tuberculosis is alarming.

Acute respiratory failure in Pakistani patients: risk factors associated with mortality.

OBJECTIVE: To assess the outcome and risk factors associated with mortality in patients with acute respiratory failure (ARF). DESIGN: Observational study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, between January 1997 and June 2001. PATIENTS AND METHODS: All adult patients admitted with a medical cause of acute respiratory failure were reviewed. The primary outcome measure was mortality and secondary outcome measures were factors associated with mortality in ARF. Multiple logistic regression analysis was used to identify the independent risk factors for mortality. RESULTS: A total of 270 patients were admitted with ARF. Hypercapnic respiratory failure was seen in 186 (69%) and hypoxemic in 84 (31%) cases. Pneumonia and COPD exacerbation were the most common underlying causes of ARF. Ventilator support was required in 93 (34.4%) patients. Hospital mortality was 28%. Chronic renal failure, malignancy, hypokalemia, severe acidosis (pH <7.25) septicemia and ARDS independently correlated with mortality. Mortality rate increased sharply (84%) with the presence of three or more risk factors. CONCLUSION: Acute respiratory failure has a high mortality rate (28%). Development of ARDS or septicemia was associated with high mortality. Presence of more than one risk factor significantly increased the mortality rate.

Knowledge regarding management of tuberculosis among general practitioners in northern areas of Pakistan.

OBJECTIVE: To assess the knowledge of General Practitioners (GPs)in NWFP and northern areas of Pakistan regarding diagnosis and management of tuberculosis. METHODS: A cross-sectional survey of general practitioners (GPs) from North West Frontier Province (NWFP) and northern areas of Pakistan was done. The sampling strategy was convenience sampling. The data was collected on a structured questionnaire after taking verbal consent. RESULTS: Out of 88 GPs 43% regarded sputum microscopy and 22% chest radiograph as confirmatory tests for the diagnosis of pulmonary TB. During follow up of pulmonary TB patients, 32% doctors considered chest radiograph as the best investigation while sputum microscopy was chosen by only 28%. Eighty seven percent of GPs correctly identified TB as a droplet infection but 6% considered sexual contact to be the main mode of spread of this disease. Two third of the prescriptions, written for a 60 kg man with newly diagnosed smear-positive pulmonary TB, were not in line with national guidelines. Only 3% of the GPs knew all the five components of DOTS. CONCLUSION: Severe deficiencies were seen in the management of TB by GPs of Northern areas of Pakistan. National TB control Program must take appropriate measures to educate and train the GPs in TB management. Without involving the GPs, TB control will remain a problem in Pakistan).

Risk factors associated with development of ventilator associated pneumonia.

OBJECTIVE: To assess the risk factors associated with development of ventilator associated pneumonia (VAP). DESIGN: A case control study. PLACE AND DURATION OF STUDY: Intensive Care Unit (ICU) at the Aga Khan University Hospital, Karachi, between January 1999 and June 2000. PATIENTS AND METHODS: All patients with assisted mechanical ventilation were assessed for the development of VAP. Risk factors associated with development of VAP were determined. Adult patients who developed pneumonia, 48 hours after ventilation, were called cases while those who did not develop pneumonia were called controls. RESULTS: Seventy (28%) out of 250 mechanically ventilated patients developed VAP (rate of VAP was 26 cases per 1000 ventilator days). Shock during first 48 hours of ventilation (odds ratio (OR), 5.95; 95% confidence interval (CI), 2.83-12.52), transport out of ICU during mechanical ventilation (OR, 6.0; 95% CI, 2.92-12.37), re-intubation (OR, 4.23; 95% CI, 2.53-9.85), prior episode of aspiration of gastric content (OR, 3.07; 95% CI, 1.35-7.01), and use of antibiotics prior to intubation (OR,2.55; 95% CI, 1.20-5.41) were found to be independently associated with a higher risk of developing VAP. Gram negative organisms and Staphylococcus aureus were responsible for over 90% of cases. Patients with VAP had higher crude mortality rate (57.1%) compared with controls (32.2%). CONCLUSION: Ventilator associated pneumonia is associated with a high mortality. This study has identified risk factors associated with VAP.

Effect of providing free sputum microscopy service to private practitioners on case notification to National Tuberculosis Control Program.

BACKGROUND: This study was undertaken to see whether providing free sputum microscopy services to private practitioners helps in case notification to the national tuberculosis control program. The knowledge, attitudes and practices of these practitioners regarding tuberculosis were also evaluated. METHODS: A questionnaire was administered to all the private practitioners practicing in a densely populated area of Karachi. They were asked to fill tuberculosis notification cards for the first three months and then for another three months when an incentive in the form of free sputum microscopy was provided to the practitioners. RESULTS: Although the majority of the practitioners knew that cough, fever and weight loss are the main symptoms of tuberculosis, less than half knew that blood in sputum, poor appetite and chest pain could also be associated with tuberculosis. Only 66% of the practitioners indicated sputum microscopy as the preferred diagnostic method for tuberculosis. Only 50% of the practitioners self treated the patients, while the remaining half referred their patients to specialists. Around 80% of the practitioners were aware of the four first-line anti-tuberculosis drugs. Less than half of the practitioners considered sputum microscopy as the most useful follow-up investigation in a patient with pulmonary tuberculosis. Generally, there was a poor response in case notification by private practitioners on provision of free sputum microscopy. CONCLUSION: An overwhelming majority of the practitioners had poor knowledge concerning the correct treatment practices in Tuberculosis. Providing sputum free microscopy does not significantly help in improving tuberculosis case notification. Strategies for public-private collaboration in tuberculosis control are needed.

Pre-operative pulmonary evaluation.

Postoperative pulmonary complications contribute significantly to morbidity and morality in surgical patients. Pulmonary complications occur more frequently than cardiac complications. The complication rates for upper abdominal and thoracic surgery are the highest. A better understanding of the risk factors associated with postoperative pulmonary complications is essential to develop strategies for reducing these complications. In any individual patient the benefit from a surgical procedure should be weighed against the risks it imposes. When possible, stabilization of respiratory status is advisable before surgery. This article reviews patient and procedure related risk factors, clinical and laboratory evaluation for preoperative risk assessment and risk reduction strategies to minimize the complication rates.

Non-invasive ventilation in the management of acute respiratory failure in Pakistan.

Data were collected from hospital records on all patients who received non-invasive ventilation (NIV) during the period 1999-2000. Patients were treated with NIV if they had type I or type II respiratory failure or if they had respiratory distress with a respiratory rate above 30/min. A total of 68 patients (35 males) were studied. NIV was applied using a Respironics Bi-PAP device mostly on a high-dependency unit (HDU). A successful outcome with NIV was achieved in 70% (26/37) of patients with type II failure, 65% (11/17) patients with type I failure and 64% (9/14) patients with respiratory distress. Of the 16 patients considered to be inappropriate for invasive ventilation on admission, eight were treated successfully with NIV. NIV can be applied successfully in developing countries.

Platypnea-orthodeoxia: report of two cases and review of the literature.

We describe two unusual cases of platypnea. The first patient had chronic obstructive pulmonary disease, but platypnea did not respond to chronic obstructive pulmonary disease therapy. He was found to have multiple pulmonary emboli, and symptoms rapidly improved on anticoagulation therapy. The second patient had Parkinson disease and developed severe platypnea, an association that has not been previously described. She had significant postural hypotension and responded to therapy with fludrocortisone.

Chronic pulmonary thromboembolism.

Chronic pulmonary thromboembolism is a rare but treatable cause of pulmonary hypertension. We are describing two patients with limited mobility and dyspnoea. Neither of the patients had clinical evidence of deep vein thrombosis. A high level of clinical suspicion is required for the diagnosis. Spiral CT scan establishes the diagnosis avoiding the need for pulmonary angiography. Surgical endarterectomy is the treatment of choice. Life-long anticoagulation therapy is recommended for patients in whom surgery cannot be performed. Untreated, the condition carries a high mortality.

General physicians' perspective of sleep apnea from a developing country.

To assess the knowledge of general physicians about the diagnosis and management of obstructive sleep apnea (OSA), a self-administered questionnaire, containing 15 questions, was distributed to 160 doctors attending a pulmonary CME program in March 2002. After 15 minutes of response time, the questionnaires were collected. The data were entered and analyzed using SPSS (Version 10.0) software. One hundred and twenty (75%) questionnaires were returned. Only 41% of responders had ever read an article about OSA and 36% had suspected it at least once in their practice. The majority (61-77%) of responders were aware of the common symptoms of OSA, but 55% did not recognize its association with hypertension. A significant number of doctors were not aware that OSA could occur in non-obese individuals (33%), women (42%) and children (39%). Only 25% of responders recognized that a history and blood tests were insufficient to make a reliable diagnosis of OSA. Half of the responders were aware of CPAP therapy for OSA, whereas 18% would have prescribed sedatives to treat sleep disturbances in OSA.