New pneumothorax complicating successful treatment of persistent air leak by endobronchial valves.

Endobronchial one-way valves (EBV) have been proposed as a treatment option for persistent air leak (PAL) complicating spontaneous pneumothorax when surgical intervention is considered not feasible. Published case series showed this form of treatment to be generally safe. We report two such cases in which both achieved immediate cessation of air leak and post-procedural chest radiograph showed significant collapse of the treated lobe, but developed sudden onset of shortness of breath within 24 h after EBV insertion. Chest radiograph showed continued collapse of the treated lobes with enlarged ipsilateral pneumothorax in one patient and new contralateral pneumothorax in the other. Pulmonologists and thoracic surgeons inserting EBV for treatment of PAL should be aware of this possible and important complication.

Clamping of chest drain before removal in spontaneous pneumothorax.

BACKGROUND: In spontaneous pneumothorax, clamping the chest drain before its removal may avoid reinsertion in case of early recurrence, but may be unsafe and may prolong hospital stay. The objective of this study was to examine the incidence of early recurrence in both clamped and unclamped pneumothorax episodes, and factors associated with it. METHODS: Retrospective chart review of primary and secondary spontaneous pneumothorax episodes in which chest drain was inserted during the period April 2012 to March 2014. RESULTS: Data of 122 episodes were analysed. There were 36 primary pneumothorax and 86 secondary pneumothorax episodes. Mean age was 59 years with 92% males. Clamping of the chest drain was done in 68 episodes (55.7%), and not done in 54. The clamping group was significantly younger, had more primary pneumothorax, and had shorter time from cessation of air leak to clamp/removal. Recurrence within 24 h were seen in 12 (17.6%) clamped episodes and 4 (7.4%) non-clamped episodes, although in only eight episodes were reinsertion of chest drain saved. Significantly more previous pneumothorax episodes were seen in the early recurrence group. We observed no new onset of tension pneumothorax or subcutaneous emphysema associated with clamping. CONCLUSION: The practice of clamping the chest drain before removal in spontaneous pneumothorax appear safe. Clamping saved chest drain reinsertion in 11.8% of cases, and has the potential to save more if clamped for up to 24 h. However, clamping may result in more early recurrences. Prospective randomised studies are needed.

Blood Eosinophil and Risk of Exacerbation in Chronic Obstructive Pulmonary Disease Patients: A Retrospective Cohort Analysis.

Purpose: Blood eosinophil is a readily available biomarker to reflect the eosinophilic inflammation in chronic obstructive pulmonary disease (COPD) patients, yet its association with exacerbation is inconclusive. It is uncertain which measurement, eosinophil percentage or absolute eosinophil count, should be used and what is the optimal cutoff for exacerbation prediction. Patients and Methods: A total of 247 COPD patients were included in this retrospective cohort study. Blood eosinophil during stable disease state, baseline demographics, and clinical characteristics in 12 months after the index complete blood count (CBC) were recorded. Exacerbation frequencies were compared between patients with high and low blood eosinophil percentage using 2% as cut-off. Logistic regression and receiver operating characteristics (ROC) curve analyses were conducted. Results: Patients with blood eosinophil ≥2% were associated with more frequent exacerbations than patients with eosinophil <2% in the 12 months after the index CBC (mean exacerbation 1.07 vs 0.34, p < 0.001). Higher blood eosinophil percentage conferred a higher risk of exacerbation. Adjusted odds ratio for exacerbation in 12 months after the index CBC for blood eosinophil ≥2% was 2.98 (95% confidence interval = 1.42-6.25). The area under the ROC curve of eosinophil percentage was significantly higher than that of absolute eosinophil count (0.678 vs 0.640, p = 0.010). The optimal cutoff of blood eosinophil percentage for exacerbation prediction was 2.8%. Conclusion: Blood eosinophilia was associated with higher exacerbation risk in COPD patients. Further studies are required to elucidate the mechanism of eosinophilic inflammation in COPD and determine the optimal treatment strategy to reduce exacerbations.

Associations between Coffee Products and Breast Cancer Risk: a Case-Control study in Hong Kong Chinese Women.

Coffee contains caffeine and diterpenes that were associated with decreased breast cancer risk, but results remained inconsistent. The study purpose was to investigate the associations between coffee products and breast cancer risk among Hong Kong Chinese women. We conducted a hospital-based case-control study in three public hospitals. 2169 Chinese women aged 24-84 years old were interviewed using a standardized questionnaire with questions asking types, cups and duration on coffee drinking. We used unconditional multivariate logistic regression to calculate the adjusted odds ratio (AOR) and 95% confidence interval (95% CI) for breast cancer risk with different coffee products. 238 (20.6%) cases and 179 (17.7%) controls are habitual coffee drinkers. No association was found between overall coffee drinking and breast cancer risk. Compared to the non-habitual coffee drinkers, women who consumed instant coffee (AOR = 1.50, 95% CI = 1.10-2.03) were significantly associated with an increased breast cancer risk. Women who drank brewed coffee (AOR = 0.48, 95% CI = 0.28-0.82) were negatively associated with breast cancer risk. A positive association between instant coffee and breast cancer risk was observed, contradicted to the outcomes of drinking brewed coffee. Larger studies are warranted to ascertain the role of different types of coffee products in breast cancer risk.

Endobronchial one-way valve for persistent air leak and lung volume reduction.

There are randomized controlled study data showing that endobronchial one-way valves (EBV) are useful for bronchoscopic lung volume reduction (BLVR). There is also case series data showing EBV to be effective in stopping persistent air leaks complicating pneumothoraces. We describe a 66-year-old man with severe chronic obstructive pulmonary disease (COPD) who failed assessments for BLVR because of the inability to perform the carbon monoxide diffusion test but subsequently had EBV deployed to his right upper lobe bronchi for persistent air leak complicating a spontaneous pneumothorax. Afterwards, there was subjective improvement in breathlessness, exercise capacity, and reduced frequency of exacerbations requiring hospitalization. Lung function parameters showed marked improvement. This case suggests that patients with compatible spirometric lung volume and computed tomography findings should proceed with BLVR. In addition, one should be aware of the possibility of improved lung function in patients with pulmonary emphysema following implantation of EBV for persistent air leak.

SF-6D utility scores of smokers and ex-smokers with or without respiratory symptoms attending primary care clinics.

INTRODUCTION: The aim of this paper is to find out generic preference-based Short-Form 6 Dimensions (SF-6D) utility scores of smokers and ex-smokers with varying cigarette exposure, with and without respiratory symptoms. METHODS: Seven hundred thirty one people aged ≥30 with a history of smoking who attended 5 public primary care clinics completed a cross-sectional survey using SF-6D utility score, Breathlessness, Cough, and Sputum Scale (BCSS©) and office spirometry. RESULTS: Most of the subjects were men (92.5%) in an older age group (mean age 62.2 ± 11.7 years). About half of them (48.3%) were current smokers while the other half (51.7%) were ex-smokers. More than half of them (54.2%) reported mild respiratory symptoms (mean BCSS score 0.95 ± 1.12). The most common symptoms were sputum (45.1%), followed by cough (34.2%) and breathlessness (6.0%). The SF-6D overall utility score was 0.850 ± 0.106. The subjects reported significantly lower SF-6D scores when they had breathlessness (0.752 ± 0.138; p = < 0.001), cough (0.836 ± 0.107; p = 0.007), sputum (0.838 ± 0.115; p = 0.004) or any of the above symptom (0.837 ± 0.113; p < 0.001). In both groups of current smokers and ex-smokers, there was no statistically significant difference in the scores among light, moderate or heavy smokers. In the Tobit regression model of factors affecting SF-6D utility score, subjects who reported more respiratory symptoms (i.e. higher BCSS©) had lower SF-6D scores (B = - 0.018 ± 0.007, p < 0.001), while men had higher SF-6D scores than women (B = 0.037 ± 0.031, p = 0.019). Subjects who attended middle or high school had higher SF-6D score than those attended the University or above. The presence of airflow obstruction was not associated with the score. CONCLUSIONS: The study yielded SF-6D utility scores of smokers and ex-smokers with different reported cigarette exposure, which could be useful in future clinical studies and cost-effectiveness analysis.

Comorbidities, mortality, and management of chronic obstructive pulmonary disease patients who required admissions to public hospitals in Hong Kong - computerized data collection and analysis.

Background: COPD is a common cause for hospital admission. Conventional studies of the epidemiology of COPD involved large patient number and immense resources and were difficult to be repeated. The present study aimed at assessing the utilization of a computerized data management system in the collection and analysis of the epidemiological and clinical data of a large COPD cohort in Hong Kong (HK). Patients and methods: It was a computerized, multicenter, retrospective review of the characteristics of patients discharged from medical departments of the 16 participating hospitals with the primary discharge diagnosis of COPD in 1 year (2012). Comparison was made between the different subgroups in the use of medications, ventilatory support, and other health care resources. The mortality of the subjects in different subgroups was traced up to December 31, 2014. The top 10 causes of death were analyzed. Results: In total, 9,776 subjects (82.6% men, mean age = 78 years) were identified. Of the 1,918 subjects with lung function coding, 85 (4.4%), 488 (25.5%), 808 (42.1%), and 537 (28.0%) subjects had the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1, 2, 3, and 4 classes, respectively. Patients with higher GOLD classes had higher number of hospital admissions, longer hospital stay, increased usage of noninvasive mechanical ventilation (NIV), combinations of long-acting bronchodilators, and higher mortality. Of the 9,776 subjects, 2,278 (23.3%) received NIV, but invasive mechanical ventilation was uncommon (134 of 9,776 subjects [1.4%]); 4,427 (45.3%) subjects had died by the end of 2014. The top causes of death were COPD, pneumonia, lung cancer, and other malignancies. Conclusion: Patients admitted to hospitals for COPD in HK had significant comorbidities, mortality, and imposed heavy burden on health care resources. It is possible to collect and analyze data of a large COPD cohort through a computerized system. Suboptimal coding of lung function results was observed, and underutilization of long-acting bronchodilators was common.

CC16 levels correlate with cigarette smoke exposure in bronchial epithelial cells and with lung function decline in smokers.

BACKGROUND: Club cell protein-16 (CC16) expression has been associated with smoking-related lung function decline. The study hypothesis was that CC16 expression in both serum and bronchial epithelium is associated with lung function decline in smokers, and exposure to cigarette smoke will lead to reduction in CC16 expression in bronchial epithelial cells. METHODS: In a cohort of community-based male Chinese subjects recruited for lung function test in 2000, we reassessed their lung function ten years later and measured serum levels of CC16. CC16 expression was further assayed in bronchial epithelium from endobronchial biopsies taken from an independent cohort of subjects undergoing autofluorescence bronchoscopy, and tested for correlation between CC16 immunostaining intensity and lung function. In an in-vitro model, bronchial epithelial cells were exposed to cigarette smoke extract (CSE), and the expression levels of CC16 were measured in bronchial epithelial cells before and after exposure to CSE. RESULTS: There was a significant association between FEV1 decline and serum CC16 levels in smokers. Expression of CC16 in bronchial epithelium showed significant correlation with FEV1/FVC. Bronchial epithelial cells showed significant decrease in CC16 expression after exposure to CSE, followed by a subsequent rise in CC16 expression upon removal of CSE. CONCLUSIONS: Results of these clinical and laboratory investigations suggested that low serum CC16 was associated with smoking-related decline in lung function, demonstrated the first time in a Chinese cohort. The data also lend support to the putative role of CC16 in protection against smoking-related bronchial epithelial damage. (Abstract word count: 243) US CLINICAL TRIAL REGISTRY: NCT01185652 , first posted 20 August, 2010.

Disparities of time trends and birth cohort effects on invasive breast cancer incidence in Shanghai and Hong Kong pre- and post-menopausal women.

BACKGROUND: Breast cancer is the leading cause of cancer morbidity among Shanghai and Hong Kong women, which contributes to 20-25% of new female cancer incidents. This study aimed to describe the temporal trend of breast cancer and interpret the potential effects on the observed secular trends. METHODS: Cancer incident data were obtained from the cancer registries. Age-standardized incidence rate was computed by the direct method using the World population of 2000. Average annual percentage change (AAPC) in incidence rate was estimated by the Joinpoint regression. Age, period and cohort effects were assessed by using a log-linear model with Poisson regression. RESULTS: During 1976-2009, an increasing trend of breast cancer incidence was observed, with an AAPC of 1.73 [95% confidence interval (CI): 1.54-1.92)] for women in Hong Kong and 2.83 (95% CI, 2.26-3.40) in Shanghai. Greater upward trends were revealed in Shanghai women aged 50 years old or above (AAPC = 3.09; 95% CI, 1.48-4.73). Using age at 50 years old as cut-point, strong birth cohort effects were shown in both pre- and post-menopausal women, though a more remarkable effect was suggested in Shanghai post-menopausal women. No evidence for a period effect was indicated. CONCLUSIONS: Incidence rate of breast cancer has been more speedy in Shanghai post-menopausal women than that of the Hong Kong women over the past 30 years. Decreased birth rate and increasing environmental exposures (e.g., light-at-night) over successive generations may have constituted major impacts on the birth cohort effects, especially for the post-menopausal breast cancer; further analytic studies are warranted.

Nighttime eating and breast cancer among Chinese women in Hong Kong.

BACKGROUND: A novel line of research suggests that eating at nighttime may have several metabolic consequences that are highly relevant to breast cancer. We investigated the association between nighttime eating habits after 10 p.m. and breast cancer in Hong Kong women. METHODS: A hospital-based case-control study was conducted during 2012-2015. A total of 922 patients with incident breast cancer (cases) and 913 hospital controls were recruited and interviewed using a standard questionnaire including information on eating behavior during both daytime and nighttime. We collected the timing, duration, types and frequencies of food intake of eating at nighttime. Odds ratios (ORs) for the risk of breast cancer in relation to nighttime eating-related variables were calculated by unconditional multivariable logistic regression. RESULTS: Eating at night after 10 pm was significantly associated with breast cancer with an adjusted OR of 1.50 (95% confidence interval (CI) 1.06-2.12, P = 0.02), and the associations were stronger in women who had the longest duration of nighttime eating (≥20 years) (adjusted OR = 2.28 (95% CI 1.13-4.61, P = 0.02) and who ate late (midnight to 2 a.m.) (adjusted OR = 2.73, 95% CI 1.01-6.99, P = 0.04). Interestingly, nighttime eating was only associated with breast cancer among women who consumed staple foods (OR = 2.16, 95% CI 1.42-3.29, P < 0.001) but not those who ate vegetables or fruits as nighttime meals. The significant association between nighttime eating and breast cancer was observed among women with body mass index (BMI) <25 (OR = 2.29, 95% CI 1.48-3.52, P < 0.001) but not among women with BMI ≥25. CONCLUSIONS: Results from this study suggest a possible association between nighttime eating behavior and breast cancer. These findings need to be confirmed by independent large studies.

Prevalence of undiagnosed airflow obstruction among people with a history of smoking in a primary care setting.

PURPOSE: The purpose of this study was to define the prevalence of undiagnosed airflow obstruction (AO) among subjects with a history of smoking but no previous diagnosis of chronic lung disease. The finding of AO likely represents diagnosis of chronic obstructive pulmonary disease. PATIENTS: People aged ≥30 years with a history of smoking who attended public outpatient clinics for primary care services were included in this study. METHODS: A cross-sectional survey in five clinics in Hong Kong using the Breathlessness, Cough, and Sputum Scale, the Lung Function Questionnaire, and office spirometry was conducted. RESULTS: In total, 731 subjects (response rate =97.9%) completed the questionnaires and spirometry tests. Most of the subjects were men (92.5%) in the older age group (mean age =62.2 years; standard deviation =11.7). Of the 731 subjects, 107 had AO, giving a prevalence of 14.6% (95% confidence interval =12.1-17.2); 45 subjects with AO underwent a postbronchodilator test. By classifying the severity of chronic obstructive pulmonary disease using the Global Initiative for Chronic Obstructive Lung Disease, 27 (60%) were considered to be in mild category and 18 (40%) in moderate category. None of them belonged to the severe or very severe category. The total score of Lung Function Questionnaire showed that majority of the subjects with AO also had chronic cough, wheezing attack, or breathlessness, although most did not show any acute respiratory symptoms in accordance with the Breathlessness, Cough, and Sputum Scale. Diagnosis of AO was positively associated with the number of years of smoking (odds ratio =1.044, P=0.035) and being normal or underweight (odds ratio =1.605, P=0.046). It was negatively associated with a history of hypertension (odds ratio =0.491, P=0.003). CONCLUSION: One-seventh of smokers have undiagnosed AO. Spirometry screening of smokers should be considered in order to diagnose AO at an early stage, with an emphasis on smoking cessation.

Risk assessment model for invasive breast cancer in Hong Kong women.

No risk assessment tool is available for identifying high risk population of breast cancer (BCa) in Hong Kong. A case-control study including 918 BCa cases and 923 controls was used to develop the risk assessment model among Hong Kong Chinese women.Each participant received an in-depth interview to obtain their lifestyle and environmental risk factors. Least absolute shrinkage and selection operator (LASSO) selection model was used to select the optimal risk factors (LASSO-model). A risk score system was constructed to evaluate the cumulative effects of selected factors. Bootstrap simulation was used to test the internal validation of the model. Model performance was evaluated by receiver-operator characteristic curves and the area under the curve (AUC).Age, number of parity, number of BCa cases in 1st-degree relatives, exposure to light at night, and sleep quality were the common risk factors for all women. Alcohol drinking was included for premenopausal women; body mass index, age at menarche, age at 1st give birth, breast feeding, using of oral contraceptive, hormone replacement treatment, and history of benign breast diseases were included for postmenopausal women. The AUCs were 0.640 (95% CI, 0.598-0.681) and 0.655 (95% CI, 0.621-0.653) for pre- and postmenopausal women, respectively. Further subgroup evaluation revealed that the model performance was better for women aged 50 to 70 years or ER-positive.This BCa risk assessment tool in Hong Kong Chinese women based on LASSO selection is promising, which shows a slightly higher discriminative accuracy than those developed in other populations.

Efficacy and tolerability of budesonide/formoterol added to tiotropium compared with tiotropium alone in patients with severe or very severe COPD: A randomized, multicentre study in East Asia.

BACKGROUND AND OBJECTIVE: Triple combination therapy with tiotropium plus budesonide/formoterol has improved lung function and reduced exacerbation risk in patients with chronic obstructive pulmonary disease (COPD) in Western countries, but no such data exist for East Asian patients. This study aimed to evaluate the efficacy and tolerability of adding budesonide/formoterol to tiotropium compared with tiotropium alone in East Asian patients with severe/very severe COPD. METHODS: This 12-week, randomized, parallel-group, multicentre, open-label study was conducted in East Asia. After a 14-day run-in period during which patients received tiotropium 18 µg once daily, patients were randomized to tiotropium (18 µg once daily) + budesonide/formoterol (160/4.5 µg 2 inhalations twice daily) or tiotropium alone (18 µg once daily). The primary endpoint was change from baseline in pre-dose forced expiratory volume in 1 s (FEV1 ) to the mean of values measured at Weeks 1, 6 and 12. RESULTS: Pre-dose FEV1 significantly increased from baseline with tiotropium plus budesonide/formoterol (n = 287) versus tiotropium alone (n = 291) (5.0% vs 0.6%; treatment difference: 4.4% (95% CI: 1.9-6.9), P = 0.0004). Triple therapy also reduced the COPD exacerbation rate by 40.7% (P = 0.0032) and prolonged time to first exacerbation (38.6% risk reduction, P = 0.0167) versus tiotropium alone and markedly improved health-related quality of life (HRQoL), measured using the St George's Respiratory Questionnaire. Incidence of adverse events was 26% for both groups. CONCLUSIONS: In East Asian patients with severe/very severe COPD, adding budesonide/formoterol to tiotropium was associated with significant improvements in FEV1 and HRQoL and lower COPD exacerbation rates. Treatment was generally well tolerated. CLINICAL TRIAL REGISTRATION: NCT01397890 at Clinicaltrials.gov.

Evaluation of breast cancer risk associated with tea consumption by menopausal and estrogen receptor status among Chinese women in Hong Kong.

PURPOSE: Experimental studies implicate tea and tea polyphenols may be preventive against breast cancer, but evidence from epidemiological studies has been inconsistent. We conducted a hospital-based case-control study to evaluate the role of tea especially green tea in breast cancer etiology. METHODS: We consecutively recruited 756 incident breast cancer cases and 789 hospital controls who had completed information on tea consumption. We calculated odds ratios (ORs) for tea consumption using unconditional multivariable logistic regression. We further conducted stratified analyses to assess whether the effect of tea consumption varied by menopausal status and estrogen receptor (ER). RESULTS: Overall, 439 (58.1%) breast cancer cases and 434 (55.0%) controls reported habits of regular tea drinking, showing an adjusted OR of 1.01 (95%CI: 0.78-1.31) and 1.20 (95%CI: 0.80-1.78) for any tea and green tea drinking, respectively. Regular tea drinking was significantly associated with a lower risk for breast cancer in pre-menopausal women (OR=0.62, 95%CI: 0.40-0.97) but an increased risk in post-menopausal women (OR=1.40, 95%CI: 1.00-1.96). The positive association among postmenopausal women was strongest among ER-negative green tea drinkers (OR=2.99, 95% CI: 1.26-7.11). CONCLUSIONS: Tea or green tea drinking was not associated with overall breast cancer risk, which may be masked by the differential effect in pre- and post-menopausal women.

Familial risks and estrogen receptor-positive breast cancer in Hong Kong Chinese women.

PURPOSE: The role of family history to the risk of breast cancer was analyzed by incorporating menopausal status in Hong Kong Chinese women, with a particular respect to the estrogen receptor-positive (ER+) type. METHODS: Seven hundred and forty seven breast cancer incident cases and 781 hospital controls who had completed information on family cancer history in first-degree relatives (nature father, mother, and siblings) were recruited. Odds ratio for breast cancer were calculated by unconditional multiple logistic regression, stratified by menopausal status (a surrogate of endogenous female sex hormone level and age) and type of relative affected with the disease. Further subgroup analysis by tumor type according to ER status was investigated. RESULTS: Altogether 52 (6.96%) breast cancer cases and 23 (2.95%) controls was found that the patients' one or more first-degree relatives had a history of breast cancer, showing an adjusted odds ratio (OR) of 2.41 (95%CI: 1.45-4.02). An excess risk of breast cancer was restricted to the ER+ tumor (OR = 2.43, 95% CI: 1.38-4.28), with a relatively higher risk associated with an affected mother (OR = 3.97, 95%CI: 1.46-10.79) than an affected sister (OR = 2.06, 95%CI: 1.07-3.97), while the relative risk was more prominent in the subgroup of pre-menopausal women. Compared with the breast cancer overall, the familial risks to the ER+ tumor increased progressively with the number of affected first-degree relatives. CONCLUSIONS: This study provides new insights on a relationship between family breast cancer history, menopausal status, and the ER+ breast cancer. A separate risk prediction model for ER+ tumor in Asian population is desired.

A comparison between the EQ-5D and the SF-6D in patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND: The appropriate use of generic preference-based measures determines the accuracy of disease assessment and further decision on healthcare policy using quality adjusted life years. The discriminative capacity of different instruments would differ across disease groups. Our study was to examine the difference in utility scores for COPD patients measured by EQ-5D and SF-6D and to assist the choice of a proper instrument in this disease group. METHODS: Differences of mean utility scores of EQ-5D and SF-6D in groups defined by socio-demographic characteristics, comorbidities, health service utilisation and severity of illness were tested using Mann-Whitney test, t-test, Kruskal-Wallis test, Pearson's correlation coefficient and ANOVA, as appropriate. The discriminative properties of the two instruments were compared against indicators of quality of life using receiver operating characteristic curves. The statistical significance of the area under the curves (AUC) was tested by ANOVA and F-statistics used to compare the efficiency with which each instrument discriminated between disease severity groups. RESULTS: Mean utility scores of EQ-5D and SF-6D were 0.644 and 0.629 respectively in the 154 subjects included in the analysis. EQ-5D scores were significantly higher than SF-6D in groups less severe and these differences corresponded to a minimally important difference of greater than 0.03 (p<0.001). EQ-5D and SF-6D scores were strongly correlated across the whole sample (r = 0.677, p<0.001) and in pre-defined groups (r>0.5 and p<0.05 for all correlation coefficients). AUCs were above 0.5 against the indicators of health-related quality of life for both instruments. F-ratios suggested SF-6D was more efficient in discriminating cases of different disease severity than EQ-5D. CONCLUSIONS: Both EQ-5D and SF-6D appeared to be valid preference-based measures in Chinese COPD patients. SF-6D was more efficient in detecting differences among subgroups with differing health status. EQ-5D and SF-6D measured different things and might not be used interchangeably in COPD patients.

Spirometry is underused in the diagnosis and monitoring of patients with chronic obstructive pulmonary disease (COPD).

Spirometry is important in the diagnosis and management of chronic obstructive pulmonary disease (COPD), yet it is a common clinical observation that it is underused though the extent is unclear. This survey aims to examine the use of spirometry in the diagnosis and management of COPD patients in a district in Hong Kong. It is a cross-sectional survey involving four clinic settings: hospital-based respiratory specialist clinic, hospital-based mixed medical specialist clinic, general outpatient clinic (primary care), and tuberculosis and chest clinic. Thirty physician-diagnosed COPD patients were randomly selected from each of the four clinic groups. All of them had a forced expiratory volume in 1 second (FEV1) to forced vital capacity ratio less than 0.70 and had been followed up at the participating clinic for at least 6 months for COPD treatment. Of 126 patients who underwent spirometry, six (4.8%) did not have COPD. Of the 120 COPD patients, there were 111 males and mean post-bronchodilator FEV1 was 46.2% predicted. Only 22 patients (18.3%) had spirometry done during diagnostic workup, and 64 patients (53.3%) had spirometry done ever. The only independent factor predicting spirometry done ever was absence of old pulmonary tuberculosis and follow-up at respiratory specialist clinic. Age, sex, smoking status, comorbidities, duration of COPD, percentage predicted FEV1, body mass index, 6-minute walking distance, and Medical Research Council dyspnea score were not predictive. We conclude that spirometry is underused in general but especially by nonrespiratory physicians and family physicians in the management of COPD patients. More effort at educating the medical community is urgently needed.

Ability of procalcitonin to discriminate infection from non-infective inflammation using two pleural disease settings.

UNLABELLED: Procalcitonin has been shown to be useful in separating infection from non-infective disorders. However, infection is often paralleled by tissue inflammation. Most studies supporting the use of procalcitonin were confounded by more significant inflammation in the infection group. Few studies have examined the usefulness of procalcitonin when adjusted for inflammation.Pleural inflammation underlies the development of most exudative effusions including pleural infection and malignancy. Pleurodesis, often used to treat effusions, involves provocation of intense aseptic pleural inflammation. We conducted a two-part proof-of-concept study to test the specificity of procalcitonin in differentiating infection using cohorts of patients with pleural effusions of infective and non-infective etiologies, as well as subjects undergoing pleurodesis. METHODS: We measured the blood procalcitonin level (i) in 248 patients with pleural infection or with non-infective pleural inflammation, matched for severity of systemic inflammation by C-reactive protein (CRP), age and gender; and (ii) in patients before and 24-48 hours after induction of non-infective pleural inflammation (from talc pleurodesis). RESULTS: 1) Procalcitonin was significantly higher in patients with pleural infection compared with controls with non-infective effusions (n = 32 each group) that were case-matched for systemic inflammation as measured by CRP [median (25-75%IQR): 0.58 (0.35-1.50) vs 0.34 (0.31-0.42) µg/L respectively, p = 0.003]. 2) Talc pleurodesis provoked intense systemic inflammation, and raised serum CRP by 360% over baseline. However procalcitonin remained relatively unaffected (21% rise). 3) Procalcitonin and CRP levels did not correlate. In 214 patients with pleural infection, procalcitonin levels did not predict the survival or need for surgical intervention. CONCLUSION: Using a pleural model, this proof-of-principle study confirmed that procalcitonin is a biomarker specific for infection and is not affected by non-infective inflammation. Procalcitonin is superior to CRP in distinguishing infection from non-infective pleural diseases, even when controlled for the level of systemic inflammation.

A feasibility study to investigate the acceptability and potential effectiveness of a telecare service for older people with chronic obstructive pulmonary disease.

AIMS: To investigate the feasibility, acceptance and potential effectiveness of delivering a telecare service on the health outcomes and hospital service utilization of community-dwelling patients with chronic obstructive pulmonary disease. METHODS: Eligible participants were older people, with moderate or severe chronic obstructive pulmonary disease, and who had been admitted to hospital at least once for exacerbation during the previous year. The participants were randomly assigned to the intervention or control group. Participants in the intervention group received a telecare device kit and they were asked to monitor their oxygen saturation, pulse rate and respiration rate using the device and to transmit the data to an online network platform. A medication and purse-lip breathing reminder with a feedback function is also provided in the device kit. A community nurse monitors changes in the physiological parameters and takes immediate action to address the patients' needs. Participants in the control group received no other extra care. Study outcomes include user satisfaction, health-related quality of life, pulmonary function, hospital re-admission and use of emergency room services. RESULTS: Twenty-two participants in the intervention group and 18 in the control group were included in the analysis. The mean age of all 40 participants was 72.93 years. Overall, the participants in the intervention group expressed satisfaction with the telecare service. Some patients reported difficulty in reading the screen of the mobile phone and manipulating the tiny key-in buttons. No significant differences were found between the two time points (baseline and post-test period) with regard to health-related quality of life. No significant differences in pulmonary function and in the number of emergency department visits and hospital re-admissions between the study groups were found. CONCLUSION: The high level of user satisfaction indicated the feasibility of conducting a large-scale randomized control trial to evaluate the effects of a telecare service on health outcomes of patients with chronic obstructive pulmonary disease.

The lessons of SARS in Hong Kong.

Severe acute respiratory syndrome (SARS) is a novel coronavirus infection which broke out in Hong Kong in March 2003. Princess Margaret Hospital was designated to manage this new, mysterious and serious disease. Healthcare workers had to work under extremely stressful and often risky conditions to care for patients. Despite manpower and equipment reinforcements, staff infection occurred as a result of bodily exhaustion, working in an unfamiliar environment and lapses in infection control. Patients suffered even more, not only due to physical discomfort, but also because of the fear of isolation and death away from family and friends. Health authorities learnt their lessons in the outbreak and formulated emergency plans for future infectious disease epidemics. The healthcare infrastructure has been examined and upgraded with regard to intensive care capacity, infection control measures, professional training, manpower deployment, staff facilities, and stockpiling of drugs and personal protective equipment.