Budesonide/Formoterol (Symbicort) combination therapy as both maintenance and reliever treatment (SMART) is a novel approach in asthma management. We examined its 'real-life effectiveness' in treating Malaysian patients with moderate-to-severe asthma in whom despite on combined inhaled corticosteroids and long-acting beta2-agonist, were still inadequately controlled. In a retrospective study, 22 eligible adult patients on SMART [mean (range) age: 49 (36-65) years; FEV1: 41 (21-74)% predicted] were identified from medical records of an urban-based university hospital chest clinic, and their clinical outcomes studied at three months. Another 16 patients [50 (14-66) years; 48 (20-91)% predicted] of similar severity and treatment (i.e. Symbicort maintenance treatment plus short-acting beta2-agonist as reliever), but not on SMART, were used as comparator over the same assessment period. In addition, the patients were separately interviewed with standard questionnaire on their satisfaction and compliance to the SMART approach. In SMART group, rescue treatment requirement (p<0.001) and FEV1 [median difference = 2.5%, p=0.015; mean difference: 90 ml, p=0.013] showed significant improvement while in comparator, there was significant improvement only in the requirement for rescue treatment (p=0.023). Hospital admission rates were significantly reduced in SMART group compared to the other (p=0.039), but not in emergency treatment. Five patients asked to discontinue SMART while all others were satisfied, compliant and perceived improvement of their asthma with SMART. The maximum daily doses of inhaled budesonide and formoterol were 1400 microg and 31.5 microg respectively. Our preliminary findings suggest that SMART approach can be attempted as an effective and safe treatment option for patients with inadequately controlled moderate-to-severe asthma in Malaysian setting.
Study site: Chest clinic, Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia
In a multiracial country like Malaysia, ethnicity may influence the measurement of health-related quality of life (HRQL) in asthmatic patients. We invited 131 adult patients [44 Malays, 42 Chinese and 45 Indians; mean (95% CI) age: 43 (40.2-45.7) yrs; 28.2% male] with moderate-to-severe persistent asthma followed up in an urban-based hospital outpatient clinic to complete a disease-specific HRQL questionnaire [St Georges' Respiratory Questionnaire (SGRQ)] and to provide socio-demographic and asthma-related data. Indians reported significantly worse SGRQ total score, compared to Malays [mean (95% CI) difference: 10.15 (0.51-19.78); p = 0.037] and SGRQ activity score, compared to Malays [13.50 (1.95-25.05); p = 0.019] and Chinese [11.88 (0.19-25.05); p = 0.046]. Further analysis using multivariate linear regression showed that Indian ethnicity remained independently associated with SGRQ scores. Our finding highlights the relevance of ethnicity in assessing HRQL of asthmatic patients in a multiracial country such as Malaysia.
Study site: chest clinic of an urban-based
university teaching hospital
Delay in commencing treatment in patients diagnosed with smear-positive pulmonary tuberculosis (PTB) may promote the spread of PTB in the community. Socio-demographic and clinical data from 169 patients (119 retrospectively and 50 prospectively collected) treated for smear-positive PTB in our hospital Chest Clinic from June 2002 to February 2003 were analysed. One hundred and fifty eight (93.5%) patients were started on treatment in less than 7 days from the time when the report first became available while 11 (6.5%) patients had their treatment started > or = 7 days. The median 'discovery to treatment' window was 1 day (range, 0 to 24 days). Of the factors studied, longevity of symptoms, absence of fever or night sweats and having sought traditional medicine were associated with delay in treatment commencement. The urgency and importance of anti-TB treatment should be emphasized especially to patients who are inclined towards treatment with traditional medicine.
Keywords: Smear positive, pulmonary tuberculosis, treatment delay, traditional medicine, Malaysia, Seremban, Negeri Sembilan
Perceived breathlessness played an important role in guiding treatment in asthma. We developed a simple, user-friendly method of scoring perception of dyspnoea (POD) using an incentive spirometer, Triflo II (Tyco Healthcare, Mansfield, USA) by means of repetitive inspiratory efforts achieved within three minutes in 175 normal healthy subjects and 158 asthmatic patients of mild (n=26), moderate (n=78) and severe (n=54). Severity was stratified according to GINA guideline. The mean POD index in normal subjects, and asthmatic patients of mild, moderate and severe severity were: 6 (4-7) 16 (9-23), 25 (14-37), and 57 (14-100) respectively (p<0.001 One-Way ANOVA). Based on 17 asthmatic and 20 normal healthy subjects, intraclass correlation coefficients for POD index within subjects were high. In 14 asthmatic patients randomized to receiving nebulised b(2)-agonist or saline in a crossover, double-blind study, % FEV(1) change correlated with % changes in POD index [r(s) -0.46, p=0.012]. Finally, when compared with 6-minutes walking test (6MWT) in an open label study, respiratory POD index correlated with walking POD index in 21 asthmatic patients [r(s)= 0.58 (0.17 to 0.81) (p=0.007] and 26 normal subjects [0.50 (0.13 to 0.75) (p=0.008)]. We concluded that this test is discriminative between asthmatic patients of varying severity and from normal subjects, is reproducible, responsive to bronchodilator effect, and comparable with 6MWT. Taken together, it has the potential to score disability and POD in asthma effectively and simply.
The prognosis of lung cancer remains poor with overall five year survival figures varying between five and 10% worldwide, However, it has been shown that surgery in patients with early stage disease in non-small cell lung cancer can achieve five year survival rates up to 80%, suggesting that early or delay diagnosis can influence prognosis. Nevertheless, studies addressing this have been inconclusive and mostly derived from Western countries.
In the Malaysian setting of multi-ethnicity and high BCG coverage, interpretation of Tuberculin Skin Testing (TST) may be difficult. Between January 2001 and December 2003, a retrospective study on all adult patients with documented TST results treated for tuberculosis (TB) in chest clinics of two government hospitals was conducted to determine the reliability of TST and factors affecting its interpretation. One hundred and three patients [mean age (SD): 43 (17); male: 67%] were eligible for data collection: 72% and 57% of patients had positive TST results based on cut-off points of 10mm and 15mm respectively. The only significant univariate association with TST results was the severity of co-morbidity. A patient with co-morbidity score of 3 defined as those with any cancer, end-stage renal or liver disease, or HIV disease, was more likely to have a negative TST results [10mm cut-off point: Odd Ratio (95% CI) 6.6 (1.82 to 24.35), p = 0.003; 15mm cut-off point: 4.8 (1.21 to 18.95), p = 0.012]. A TST reading of 10mm had a higher sensitivity than 15mm as the cut-off point in diagnosing TB infection. Considering all possible confounding factors like ethnicity, prior BCG vaccination and TB burden in the population, severity of co-morbidity remains strongly predictive of a negative TST. Caution should be exercised in interpreting TST in these patients.
Study site: Chest clinic, Hospital Seremban, Hospital Kuala Pilah, Negeri Sembilan, Malaysia
Inefficient metered-dose inhaler (MDI) technique results in poor drug delivery, suboptimal disease control a possibility of inhaled medication overuse. The MDI technique of 134 government hospital and clinic followed-up adult asthmatic patients followed-up in a government hospital and a heath clinic was pragmatically assessed based on the 3 obligatory steps of adequate lip seal, appropriate hand-breath coordination and sufficient breath holding after inhalation. The relationship between technique efficiency and frequency of daily short-acting beta2-agonist (SABA) use via the MDI and asthma exacerbations over a 12-month period was also assessed. Fifty-six patients (42%) had inefficient MDI technique. All demographic and asthma-related variables between the 'efficient' and 'inefficient' technique groups of patients were comparable except for significantly longer mean years of MDI use in the 'efficient' technique group [mean (SD): 10 (7) vs. 7 (5); p=0.003]. There were no significant differences between the two groups in relation to frequency of daily SABA use or asthma exacerbations over the past 12 months. Despite having been available in Malaysia for a considerable period of time, the MDI device is still poorly handled by a large proportion of adult asthmatic patients. Changing to other more user-friendly devices or use of spacer devices to facilitate delivery should be considered for these patients.
Study site: Hospital Tuanku Jaafar, Seremban, Negeri Sembilan; Klinik Kesihatan Seremban, Malaysia
Prediction of mortality in patients with community-acquired pneumonia (CAP) can be assessed using clinical severity scores on admission to hospital. The clinical benefit of such tools is untested in Asian countries. The aim of this study was to determine the early adverse prognostic factors in patients hospitalized with CAP in Malaysia and to assess the usefulness of the British Thoracic Society (BTS) severity criteria.
Airway inflammation can be demonstrated by the modem method of sputum induction using ultrasonic nebulizer and hypertonic saline. We studied whether compressed-air nebulizer and isotonic saline which are commonly available and cost less, are as effective in inducing sputum in normal adult subjects as the above mentioned tools. Sixteen subjects underwent weekly sputum induction in the following manner: ultrasonic nebulizer (Medix Sonix 2000, Clement Clarke, UK) using hypertonic saline, ultrasonic nebulizer using isotonic saline, compressed-air nebulizer (BestNeb, Taiwan) using hypertonic saline, and compressed-air nebulizer using isotonic saline. Overall, the use of an ultrasonic nebulizer and hypertonic saline yielded significantly higher total sputum cell counts and a higher percentage of cell viability than compressed-air nebulizers and isotonic saline. With the latter, there was a trend towards squamous cell contaminations. The proportion of various sputum cell types was not significantly different between the groups, and the reproducibility in sputum macrophages and neutrophils was high (Intraclass correlation coefficient, r [95%CI]: 0.65 [0.30-0.91] and 0.58 [0.22-0.89], p < 0.001). Overall changes in median FEV, were small and comparable between all groups. Induction using ultrasonic nebulizers together with hypertonic saline was generally less well tolerated than compressed-air nebulizers and isotonic saline. We conclude that in normal subjects, although both nebulizers and saline types can induce sputum with reproducible cellular profile, ultrasonic nebulizers and hypertonic saline are more effective but less well tolerated.
Pulmonary disease is sometimes treated empirically as tuberculosis (TB) in the absence of microbial confirmation if the clinical suspicion of active TB is high. In a country of relatively high TB and low HIV burden, we retrospectively studied 107 patients (69.2% male; mean age (SD): 45 (17) years) who received empirical anti-TB treatment for intrapulmonary opacities or pleural effusions suspected of active TB in our hospitals between 1998 and 2002. The diagnosis of definite or probable 'smear-negative' pulmonary TB was made based on treatment outcome at two months with rifampicin, isoniazid, pyrazinamide and ethambutol (or streptomycin). At this end-point, 81 patients (84.4%) had both clinical and radiological improvement (definite cases), 12 (12.5%) had clinical improvement alone and 3 (3.1%) had radiological improvement alone (probable cases). Confirmation of acid-fast bacilli was subsequently obtained in 12 patients (all definite cases) from culture of initial pulmonary specimens. Eleven patients (10.5%) were diagnosed as 'non-TB' based on absence of both clinical and radiological improvement or discovery of another cause for the pulmonary condition at or before this two-month study end-point. In the 'non-TB' group, 2 had carcinoma, 2 had HIV-related pulmonary diseases, 1 had bronchiectasis, while in 6 causes were indeterminate. Six (6.3%) and 3 (27.3%) patients reported adverse effects from anti-TB drugs from the 'TB' and 'non-TB' groups respectively. Our findings suggest that empirical anti-TB treatment is an acceptable practice if clinical suspicion is high in patients coming in our region.
Current clinical practice guidelines, including those in south Asia, recommend the addition of a macrolide to a broad-spectrum antibiotic for the treatment of severe hospitalized community-acquired pneumonia (CAP). The aim of this study was to observe the influence of macrolide addition on clinical outcomes of hospitalized adult patients with CAP.
The cornerstone of asthma management is achieving adequate symptom control and patient education. We studied in our local population of asthmatic patients how well their symptoms were controlled with currently prescribed treatment and their insight into the disease and its management. Over a 6-month period, 93 asthmatics recruited from two local government health clinics and a state hospital were interviewed using a standard questionnaire. Patients were classified into 4 groups based on the treatment they were on according to Global Initiative for Asthma (GINA) treatment guidelines. The number of patients in Step 1 (rescue medication alone), Step 2 (1 controller medication), Step 3 (2 controller medications) and Step 4 (at least 3 controller medications) were 8, 39, 34 and 12, respectively. Except for day symptoms in Step 1 group, fewer than 50% achieved minimum day or night symptoms and no restriction of daily activities. Questions on patient insight were only available for 50 patients. Weather change (74%), air pollution (66%) and physical stress (46%) were the three highest ranked common asthma triggers. More than half correctly recognized the important symptoms of a serious asthma attack but fewer than 15% were familiar with the peak flow meter and its use or with the asthma self-management plan. Most patients perceived that their treatment had helped reduce disease severity and exacerbations. We conclude that symptom control and some aspect of patient education are still lacking in our local asthmatics.
Study site: Hospital Tuanku Jaafar, Seremban, Negeri Sembilan; Klinik Kesihatan Seremban; Klinik Kesihatan Ampangan, Malaysia
We studied the admission criteria and first 24-hour management of 62 asthmatic patients admitted from Accident and Emergency (A&E) department of a state hospital. Data was collected prospectively over a 6-month period from the doctors' medical records with reference to recommendations of the Malaysian Thoracic Society (MTS) on management of acute asthma. Peak Expiratory Flow Rate (PEFR) records were present in only 14.5% of the A&E notes and 54.8% of the ward notes. Most of these readings were below 75% of predicted normal values. Over half of the patients had records on ability to speak full sentences, and respiratory and pulse rates. Based on other records on criteria for life-threatening features (including arterial blood gases), 42% of patients studied had life threatening asthma exacerbations. Most received appropriate treatment as recommended by the MTS. We conclude that while most patients were admitted and treated appropriately, medical documentation regarding acute asthma assessment were inadequate in some.
Study site: Hospital Tuanku Jaafar, Seremban, Negeri Sembilan, Malaysia
While evidence indicates that early stage disease has better prognosis, the effect of delay in presentation and treatment of patients with non-small cell lung cancer (NSCLC) on survival is debatable. A retrospective study of 122 Malaysian patients with NSCLC was performed to examine the presentation and treatment delay, and its relation with patient survival. Median (25-75% IQR) interval between onset of symptoms and first hospital consultation (patient delay) and between first hospital consultation and treatment or decision to treat (doctor delay) were 2 (1.0- 5.0) and 1.1 (0.6-2.4) months respectively. The median survival rates in patient delay of <1, 1 to 3, and >3 months were 4.1 (9.9-1.7), 5.1 (10.9-3.2) and 5.7 (12.3-2.1) months respectively (log rank p=0.648), while in doctor delay, <30, 30-60, >60 days, the rates were 4.1 (10.8-1.8), 7.6 (13.7-3.2) and 5.3 (16.0-3.0) months respectively (p=0.557). Most patients presented and were treated in a relatively short time, and delays did not appear to influence survival. This Asian data is consistent with those from Western population, reiterating the need for public health measures that can identify disease early..
In Malaysia, many patients opted out of cancer-specific treatment for various reasons. This study was undertaken to investigate the survival rate of patients with stages I to III non-small cell lung cancer (NSCLC) who opted out of treatment, compared with those who accepted treatment. Case records of 119 patients diagnosed with NSCLC between 1996 and 2003 in two urban-based hospitals were retrospectively examined. Survival status was ascertained from follow-up medical clinic records or telephone contact with patients or their next-of-kin. Median (25-75% IQR) survival rate for 79 patients who accepted and 22 patients who opted out of treatment, were 8.6 (16.0-3.7) and 2.2 (3.5-0.8) months respectively [log rank p< 0.001, Kaplan-Meier survival analysis]. Except for proportionately more patients with large cell carcinoma who declined treatment, there was no significant difference between the two groups in relation with age, gender, ethnicity, tumour stage, and time delays between symptom onset and treatment or decision-to-treat. We concluded that there was a small but significant survival benefit in accepting cancer-specific treatment. The findings imply that there is no effective alternative therapy to cancer-specific treatment in improving survival. However, overall prognosis for patients with NSCLC remains dismal.