Key Challenges to Understanding the Burden of Respiratory Syncytial Virus in Older Adults in Southeast Asia, the Middle East, and North Africa: An Expert Perspective.

INTRODUCTION: Respiratory syncytial virus (RSV) is a common, highly contagious pathogen and a leading cause of serious illness among infants and older adults. While existing scientific evidence has predominantly focused on the epidemiology and disease burden of RSV in infants, data in older adults remain limited in some countries, including those in Southeast Asia (SEA) and the Middle East and North Africa (MENA) region. Here, we outline the key challenges for understanding the burden of RSV in older adults in SEA and the MENA region and we propose opportunities for improving understanding and eventually reducing the impact of RSV. MAIN FINDINGS AND CONCLUSIONS: A key challenge identified by the expert group, particularly in older adults, is a lack of awareness (among healthcare professionals, policy makers, and the public) of RSV burden and the associated risks for severe outcomes. This is often confounded by the complexities of underdiagnosis, surveillance limitations, and comorbidities. To address these issues, we suggest medical education initiatives for physicians in SEA and the MENA region to better understand the need to protect older adults from RSV, and encourage more widespread routine testing to better understand the burden of RSV. We also recommend surveillance studies in these regions to provide comprehensive and accurate epidemiological data on RSV in older adults. Finally, in the absence of current surveillance data in these regions, we propose extrapolating existing global data and local pediatric data to inform the likely burden of RSV in older adults. A graphical abstract is available with this article.

Study of leptin and adiponectin as disease markers in subjects with obstructive sleep apnea.

BACKGROUND: Published studies showed conflicting results of the associations between adiponectin and leptin levels and obstructive sleep apnoea (OSA). In obese patients, plasma leptin is elevated and adiponectin is decreased, and we postulate that these adipokines could be potential markers of clinical and metabolic perturbations in patients with OSA. METHODS: 147 patients with suspected OSA had polysomnography to determine the Respiratory Disturbance Index (RDI). We measured fasting plasma glucose (FPG), fasting serum insulin, plasma leptin, adiponectin, and full lipid profile. Patients were classified on the basis of the RDI, degree of adiposity, and insulin resistance (IR) (homeostasis model assessment of insulin resistance (HOMAIR)). RESULTS: 28.6% of subjects had normal polysomnography, 34.8% had mild OSA, 19.6% had moderate OSA, and 17% had severe OSA. Obesity was more prevalent in subjects with moderate-severe OSA (47%). Adiponectin decreased significantly (P = 0.041) with increasing severity of OSA. Though BMI was significantly higher in subjects with severe OSA, paradoxically, leptin was lowest in those subjects independent of gender dimorphism. CONCLUSIONS: Adiponectin is an independent marker of disease severity in patients with OSA. The paradoxical decrease in circulating leptin, which suggests impaired secretion, deserves further studies as a potential marker of severe OSA.

Quality of life of patients with chronic obstructive pulmonary disease in the Gulf Cooperation Council countries.

OBJECTIVE: To assess the health-related quality of life (HRQL) of patients with chronic obstructive pulmonary disease (COPD) in 4 Gulf Council Cooperation (GCC) countries. METHODS: We conducted a cross-sectional survey between December 2011 and March 2012 in the following countries: Kingdom of Saudi Arabia (Riyadh, Dammam, and Jeddah), Kuwait, Bahrain, and the United Arab Emirates. The HRQL was measured using the COPD Assessment Test (CAT) and the Chronic Respiratory Disease Questionnaire-Self-Administered Standardized questionnaire (CRQ-SAS). RESULTS: We recruited 120 patients from 6 centers in 4 countries. Their average forced expiratory volume (FEV)1 was 49.3% ( +/- 13.4) of predicted, and the ratio of FEV1 to forced vital capacity was 0.58 ( +/- 0.11). The average COPD Assessment Test (CAT) score was 20.4 +/- 7.6; CAT scores were highest for Riyadh (24.1 +/- 7.7) and lowest for Kuwait (18.5 +/- 9.2), with no significant difference between the centers. For the CRQ-SAS, the dyspnea domain score was 4.6 +/- 1.6, the fatigue domain score was 4.3 +/- 1.3, the emotional domain was 4.6 +/- 1.2, and the mastery domain was 4.8 +/- 1.4. The correlation coefficients of the association between the CAT score and the 4 domains of the CRQ-SAS for all of the centers combined was statistically significant. CONCLUSION: The CAT and CRQ-SAS revealed that the patients with COPD experienced a moderate to severe impact from the disease, and a considerably compromised quality of life in the GCC countries.

Purpureocillium lilacinum as a cause of cavitary pulmonary disease: a new clinical presentation and observations on atypical morphologic characteristics of the isolate.

The first case of cavitary pulmonary disease caused by Purpureocillium lilacinum is described. The isolate showed atypical microscopic characteristics similar to Acremonium and Fusarium spp., which necessitated molecular identification by sequencing of multiple conserved loci. The patient responded to voriconazole, reinforcing its therapeutic efficacy for P. lilacinum infections.

Putative roles of circulating resistin in patients with asthma, COPD and cigarette smokers.

AIMS: To investigate the hypothesis that circulating resistin reflects the degree of pulmonary inflammation, this study explores putative roles of resistin in patients with acute and stable inflammatory obstructive airway diseases and cigarette smokers. METHODS: We determined complements C3, C4, fasting resistin, insulin, glucose and lipid profile; calculated insulin resistance (homeostasis model assessment (HOMA-IR) in patients with acute asthma exacerbation (n=34); stable asthma (n=26) and stable chronic obstructive pulmonary disease (COPD; n=26), cigarette smokers (n=81), and healthy control subjects (n=42). We determined the associations between these variables and pulmonary function tests. RESULTS: Patients with COPD, acute and stable asthma had significantly higher resistin and insulin than control subjects. Resistin, insulin, HOMA-IR, FEV1% and FEV1/FVC were significantly (p< 0.05) different between patients with acute asthma compared with stable asthma and COPD; smokers had similar levels of resistin, C3 and C4 as patients with asthma and COPD. In smokers, patients with asthma or COPD, resistin showed significant inverse correlations with FEV1%; FEV1/FVC% and positive significant correlations with BMI and HOMA-IR. Logistic regression showed that resistin is associated (p< 0.05) with inflammatory obstructive airways disease - odds ratio (OR)=1.22 and smoking OR=1.18. CONCLUSION: Resistin may be a disease activity marker and may contribute to insulin resistance in smokers, asthma and COPD.

Effect of smoking habit on circulating adipokines in diabetic and non-diabetic subjects.

BACKGROUND: Despite the well-known inverse association between smoking and body weight, there have been conflicting reports on the association between smoking and adipokines such as leptin and adiponectin. AIM: To determine and compare whether tobacco smoking (cigarettes or sheesha) affects circulating levels of adiponectin and/or influences leptin and leptin receptor (sOb-R) concentrations and free leptin in diabetic and non-diabetic subjects. METHODS AND SUBJECTS: Fasting plasma adiponectin, leptin, sOb-R, glucose, insulin, and lipid profile were determined in 236 subjects grouped as control subjects (n = 53); non-diabetic cigarette smokers (n = 34), non-diabetic sheesha smokers (n = 38), diabetic nonsmokers (n = 75) and diabetic smokers (n = 36). Uni- and multivariate regression analyses were used to determine the associations of these variables with body mass index (BMI) and smoking. RESULTS: When compared to control subjects, smoking cigarettes or sheesha was associated with significantly higher glucose, insulin resistance, total cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL-C) and lower serum leptin, sOb-R and free leptin. The effects of smoking on BMI, leptin and sOb-R were dose-dependent. Binary logistic regression analysis showed that smoking is a significant determinant of BMI; leptin, sOb-R, free leptin index, adiponectin and LDL-C. CONCLUSIONS: We conclude that smoking sheesha does not reduce the metabolic effects of smoking. Smoking may modify leptin receptors and modulate leptin synthesis but the weight-lowering effect may not be related to leptin-induced anorectic signals.

Lupus patients with pulmonary involvement have a pro-inflammatory cytokines profile.

OBJECTIVES: The literature on cytokine response in systemic lupus erythematosus (SLE) is confusing. It is possible that different disease phenotypes have different cytokine profiles. Our aim was to examine the levels of selected pro-inflammatory and anti-inflammatory cytokines in SLE patients with and without pulmonary involvement. METHODS AND SUBJECTS: Patients with SLE were interviewed and were subjected to the pulmonary function test and high-resolution computed tomography studies. Serum levels of interleukin (IL)-6, IL-8, IL-10, Il-12, interferon (IFN) gamma, and tumor necrosis factor (TNF) alpha were estimated by enzyme-linked immunosorbent assay. RESULTS: Forty-nine of the 61 SLE patients had pulmonary involvement. Median levels of IL-8, IFNgamma, and TNFalpha were significantly higher in the pulmonary group as compared to the non-pulmonary group (p = 0.027, 0.027 and 0.002, respectively). Ratios of pro-inflammatory cytokines to anti-inflammatory cytokines were higher in the pulmonary group as compared to the non-pulmonary group as well as in the pulmonary restrictive subgroup compared to the obstructive subgroup. CONCLUSION: Lupus patients with pulmonary involvement have a stronger pro-inflammatory cytokine bias than those without pulmonary involvement.

Comparative analysis of the effects of hubble-bubble (Sheesha) and cigarette smoking on respiratory and metabolic parameters in hubble-bubble and cigarette smokers.

OBJECTIVES AND BACKGROUND: Hazard of smoking tobacco is believed to be minimized by smoking hubble-bubble (HB) instead of cigarettes. Our aims were to (i) develop an assay for estimating nicotine and cotinine; and (ii) evaluate the effect of smoking on respiratory and metabolic parameters in cigarette and HB smokers. METHODS: Urine samples were collected from 152 volunteer smokers (75 cigarette and 77 HB) as well as from 16 healthy controls. We optimized an HPLC method for the determination of nicotine and cotinine. Subjects were asked to complete a chronic respiratory symptoms questionnaire and to undergo spirometry. Fasting blood samples were collected for the determination of their lipid profile. RESULTS: The intra-assay coefficients of variation for nicotine and cotinine were 16.6% and 6.6%, respectively. The mean of cotinine in cigarette smokers (1321.4 ng/mL) was significantly (P = 0.008) higher than the mean cotinine (677.6 ng/mL) in HB smokers. The mean nicotine level in cigarette smokers (1487.3 ng/mL) was significantly (P < 0.0001) higher than the mean nicotine (440.5 ng/mL) in HB smoker. The urinary cotinine and nicotine levels of the control subjects were lower than the detection levels of the assay. The mean high-density lipoprotein cholesterol was lower in cigarette smokers (0.99 mmol/L) compared with HB smoker smokers (1.02 mmol/L) but this was not significant (P = 0.28). Spirometric values were comparable among the three groups but the chronic respiratory symptoms in the smoking groups appeared at an earlier age in the HB smokers compared with the cigarettes smokers (P < 0.05). CONCLUSION: Smoking HB does not reduce the risk of tobacco exposure and it's potentially harmful metabolites on health.

Non-invasive positive pressure ventilation in acute respiratory failure. An alternative modality to invasive ventilation at a general hospital.

OBJECTIVE: Non-invasive positive pressure ventilation (NPPV) is a relatively new modality of managing acute respiratory failure (ARF). It has not been applied before in our area. The aim of this study is to verify the use of NPPV on patients with ARF at a general hospital level. METHODS: All patients admitted at the Al-Amiri Hospital, Kuwait (a secondary medical center) between 1999 and 2001 with ARF and met the inclusion criteria were included in the study. The non-invasive mode of nasal ventilation was used as the respiratory support. RESULTS: A total of 21 patients were included in the final analysis. The major cause of ARF type 2 was chronic obstructive pulmonary disease (COPD) in 71%. The overall success rate of NPPV trials was 71.4%. In the successful trials of ARF type 2, the arterial blood gas parameters of PaCo2 (p<0.005), pH (p=0.023), and PaO2 (p<0.001) showed improvement from the first hour of intervention. Analysis of variance with repeated measurement for the arterial blood gas variables showed statistical significance of changes in favor of NPPV during initial close monitoring with p<0.001. The percentage of successful trials at the general wards was 82% versus 67% for the intensive care unit cases (ICU). Surprisingly, failure of trials related mainly to the clinical status of the patients. CONCLUSION: Non-invasive positive pressure ventilation is an effective ventilatory support in ARF in a proper clinical setting. It may be used safely in the general hospital outside the ICU.