Bronchiolitis obliterans organising peumonia BOO) is an uncommon inflammatory lung condition involving the terminal bronchioles and alveoli, which is responsive to treatment with corticosteroids. Patients usually present with dyspnoea, cough and fever. Two cases are described here; both had haemoptysis and were initially treated as community acquired pneumonia. Diagnosis was made on lung biopsy and there was rapid resolution after a course of prednisolone.
The process of case-finding was studied in 100 consecutive patients with pulmonary tuberculosis treated by the Chest Clinic, Penang Hospital. The median time from the onset of the illness until the initial medical consultation was two weeks (patient's delay). This delay was longer in males, patients with lower than secondary education and drug abusers. Only 47% of patients were put on treatment with a correct diagnosis within one month of the first consultation (doctor's delay). Almost all patients had at least one symptom suggestive of tuberculosis at presentation and the mean number of consultations before diagnosis was three. Patients who first visited government medical facilities had shorter doctor's delay than those who first saw private practitioners, and patients who first consulted a private practitioner were the least likely to be appropriately investigated by sputum examination and chest radiography. The median total delay was three months and at the time of diagnosis, 95% of patients had moderate or far advanced disease radiologically. In order to shorten doctor's delay, all medical practitioners, especially those in the private sector, should be made aware of the importance of early diagnosis and the proper management of tuberculosis. Health education campaigns for the public should also be undertaken to shorten patient's delay.
Study site: Chest clinic, Hospital Pulau Pinang, Malaysia
A study was conducted to determine the clinical factors that affect the quality of life in adult asthmatics. As part of their routine follow-up visit, 399 patients completed the SF-36 quality of life questionnaire, had peak expiratory flow rate readings (PEFR) taken and were interviewed to determine current symptom severity. The grade of severity of asthma was verified by the consultant physician in-charge. The mean age of the patients was 41.8 years and 31.8% of the patients were men. Most of the patients were Malay (64.7%), 89% had at least secondary level education and the mean duration of asthma was 17.6 years. The majority of patients had moderate or severe disease (43.6% and 55.9% respectively). For asthmatics with moderate or severe symptoms of chest tightness and/or shortness of breath, all domains of SF-36 scored significantly lower than those with mild symptoms, with the exception of the domain bodily pain. Patients with moderate/severe cough recorded significantly lower scores than those with mild cough for all domains except for bodily pain and social functioning. Only the physical functioning, role physical, general health and role emotional scores were significantly worse in those with a consultant grade of severe asthma compared to those with mild/moderate asthma. Patients with PEFR < 80% predicted had lower scores for the domains physical functioning, role physical and general health than those with PEFR > or = 80% predicted, but the scores for the other domains were similar in both groups. Quality of life is significantly impaired in adult asthmatics with current respiratory symptoms. However, consultant grade of severity of asthma and PEFR readings do not affect quality of life scores as much.
Study site: Asthma clinics, hospitals, Malaysia
A study was done on patients admitted to Penang Hospital with malignant disease in 1995. A total of 1333 patients (638 male, 695 female) with 1335 malignancies were studied. The majority (77.3%) were aged 41-80 years. The commonest cancers in males were cancers of lung, nasopharynx, colon and rectum, leukemia and larynx whereas the commonest malignancies in females were of the breast, cervix, colon and rectum, leukemia and ovarian/lung carcinoma. The average number of admissions was 2.2 and the average length of stay was 12.7 days. Cancer admissions account for a significant proportion of the inpatient workload of Penang Hospital.
An audit was done on 54 tuberculosis patients presenting to Penang Hospital who died during 1993. Active tuberculosis was the cause of death in 29 (53.7%) and 48.3% were aged under 50 years. Tuberculosis was a contributory cause of death in 8 patients and in 17 patients tuberculosis was irrelevant to the cause of death. The diagnosis of tuberculosis was made after death in 17 patients (31.5%). Late diagnosis was the most important factor resulting in death. Only 41.4% of the deaths from active tuberculosis were correctly certified in government hospitals. Medically inspected and certified deaths from tuberculosis is an unreliable indicator of tuberculosis mortality because of inaccuracies in death certification, tuberculosis deaths occurring outside hospital and tuberculosis patients undiagnosed until after death.
A study was done on 638 infants with BCG related lymphadenitis seen between August 1990 and December 1993. Most infants (86.5%) had developed symptoms by six months after vaccination and the nodes became suppurative in 317. Surgical procedures were carried out in 82 cases and the rest were managed conservatively. The mean duration to resolution was 6.6 months (range 1 to 29 months). This outbreak was related to a change from the Japan to the Pasteur strain of BCG. The incidence remained high ( > 15 per 1000 live births) despite a dose reduction from 0.1 ml to 0.05 ml, but declined when the Japan strain was reintroduced in April 1992.
Study site: Chest Clinic, Hospital Pulau Pinang, Malaysia
A study was carried out to determine the pattern of microbiological organisms causing community acquired pneumonia in adult patients admitted to Penang Hospital between November 1999 and August 2000. Altogether, 98 patients (64 males, 34 females) with a mean age (+/- S.D.) of 55.9 (+/- 19.0) (range 15 to 87) years were included in the study. Causative organisms were identified in 42 patients (42.9%). Mycobacterium tuberculosis was the commonest pathogen being identified in 15.3% of cases, followed by Klebsiella pneumoniae (7.2%), Pseudomonas aeruginosa (6.1%) and Staphylococcus aureus (5.1%). Streptococcus pneumoniae and Acinetobacter spp accounted for 3 cases each (3.1%) and Haemophilus influenzae, non-haemolytic Streptococcus, Mycoplasma pneumoniae, Salmonella typhi, Escherichia coli, Klebsiella spp and Pseudomonas spp for 1 case each (1.0%). Four patients (4.1%) had dual infections and no case of legionella pneumonia was found in this series.
Patients with upper airway obstruction from malignant disease are difficult to manage. A 62 year old patient presented with stridor and was found to have an upper tracheal tumour. Bronchoscopy, dilatation and stenting were performed successfully. The techniques and indications for the use of dynamic airway stent are discussed.
A female patient presenting with post-prandial epigastric pain and weight loss was diagnosed to have oesophageal tuberculosis by endoscopic biopsy. She responded well to standard anti-tuberculosis treatment.
A female patient who presented with left empyema thoracis caused by Actinomyces odontolyticus is reported. She responded to treatment with penicillin and metronidazole but after 3 weeks developed leucopenia complicated by gram-negative septicaemia. Leucopenia improved rapidly on withdrawal of metronidazole. Treatment was continued with a prolonged course of penicillin and she made an uneventful recovery.
A study was done on survival of patients surgically treated for lung cancer from 1995-2001. The average operative rate for 852 patients was 4.8%. In 67 surgically treated patients (54M, 13F), the commonest histological type was squamous cell carcinoma (52.2%) followed by adenocarcinoma (26.9%). The surgical-pathological stage was stage I in 52.2%. Postoperatively, five-year survival was 29%, with a median survival of 27 months. Completeness of resection was the foremost determinant of survival outcome and stage higher than stage I was an adverse prognostic factor. These results indicate that the current outlook for lung cancer patients remains poor.
Results of construct validity and reliability of the SF-36 are described, based on data from a multi-centre study on asthmatics and a population based survey. Questionnaire refinement was carried out between the two studies. Quality of data was good, with all items having less than 0.5% missing values. Floor and/or ceiling effects were observed for REE, REP, PF and SF. For scaling assumptions, correlations between each items and its hypothesized scale were all above 0.50, except for one item in PF. and for both items in SF. Item discriminant validity was an issue for items in VT, SF and MH scales. Cronbach's as for all scales exceeded the recommended 0.70 level, except for SF. Only one latent dimension was identified in principal component analysis, and only 52-53% of variance accounted for. As expected, PF shows high correlations with the physical component while MH was highly correlated with the mental component. Contrasting findings in the loadings of other scales were observed in the asthma data. Age, disease severity and presence of self-reported handicap/disability significantly affect PF, while MH demonstrates no obvious pattern with declining age. In essence, the Malay version of SF-36 could be used in Malaysia, with its generally acceptable internal consistency and validity. The caveat is in the call for additional domains of importance to Malaysians that is not covered by the instrument, and in the caution to be employed when using and construing the instrument.