Respirology (2010) 15 (Suppl.

2), 55109
Saturday 5 April Respiratory Nurses SIG Oral Poster Discussion Presentations (10301200)
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doi: 10.1111/j.1400-1843.2010.01865.x

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THE EXPRESSION OF NODS AND INFLAMMATORY CYTOKINES IN TISSUES OF MICE INFECTED WITH MYCOBACTERIUM LEPRAE DOJIN KIM, TAEJIN KANG Internal Medicine, Soonchunhyang University Hospital, BUcheon-Si, South Korea Introduction The nucleotide-oligomerization domain (NOD) is an important molecule involved in host defense. RICK/RIP2 contains a caspase recruitment domain and has been implicated in the activation of the transcriptional factor NF-kB downstream of Toll-like receptors and Nod-like receptors. In order to determine the function of Nod1 and Nod2 in M. leprae infection, Methods We measured the Nod1 and Nod2 mRNA level in tissues of nu/nu mouse infected with M. leprae. Results The expression of NOD1 and NOD2 mRNA was induced in tissues of nu/nu mice infected with M. leprae. In addition, the expression of was increased in tissues of mice and IL-1 inammatory cytokines such as TNFinfected with M. leprae, compared to those of non-infected mice. We also established HEK 293 cells to express Nod1 and Nod2 cDNA. RICK expression is, interestingly, regulated by Nod2-dependent pathway in M. leprae infection. Conclusion These results suggest that NOD family proteins may have a role in the immune response to M. leprae.

JOINT EFFECT OF ASTHMA/ATOPY AND IL-6 GENE POLYMORPHISM ON LUNG CANCER RISK AMONG LIFETIME NON-SMOKING NIGERIAN WOMEN GBOLAHAN ATANDA Social Science, University of Portharcourt, Inastraight House Jeje, Apete, Ibadan, Nigeria Introduction There is a growing recognition that inammatory pathways play an important role in malignant transformation. Chronic inammation is likely to be a key factor in the development of lung cancer, as attested to by genetic and molecular studies of inammatory markers such as cytokines and COX-2 in lung tumour tissue and gene polymorphisms in peripheral blood. Although this has recently been established in smoking-induced lung tumours, there is evidence that this may also be a key pathway among non-smokers, for whom the aetiology is incompletely understood. Epidemiologic studies have shown that tuberculosis, chronic bronchitis, emphysema, pneumonia and asthma increase risk of lung cancer among lifetime non-smokers in the United States and in Nigeria. Methods Participants were drawn from a hospital-base casecontrol study on lung cancer among Nigerian women, which has been described elsewhere. Briey, incident cases were primary lung cancers diagnosed at one of three major hospitals in Nigeria between April 1996 and September 1998. Controls were patient admitted to the same hospitals, not for malignant or chronic respiratory conditions. Cases and controls were frequency-matched by 10 year age groups, and the response rate among eligible cases and controls were 95.0 and 96.9%, respectively; written consent was obtained from all participants. Results A total of 124 cases and 162 controls were successfully genotyped. The prevalence of the G allele was 22.6%, and distribution of the genotype frequencies conformed to that expected under the HardyWeinberg equilibrium. Conclusion To our knowledge, this is the rst report to demonstrate an interaction between asthma/atopy and a cytokine gene polymorphism in inuencing risk of lung cancer among non-smokers. Our observation that a positive association between lung cancer and a past history of asthma or atopy is enhanced in persons who also possess the IL-6 CG/GG genotype supports the role of inammation as a mediator for lung carcinogenesis. Acknowledgements I would like to thank Dr. Olayiwola Alade (University Teaching Hospital), Dr. Babalola Unilag, and all teaching staff of the Lagos State University. I am grateful to the participants of the study on Lung Cancer in Nigerian Women, and to the Medical Boards of the National University Hospital. This work was funded by my father.

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APPLYING GLOBAL INITIATIVE FOR ASTHMA (GINA) AND GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE (GOLD) AT DISTRICT-LEVEL HEALTH CARE CENTERS IN HO CHI MINH CITY, VIETNAM THO NGUYEN VAN, MAI HOANG SI, THAO NGUYEN THI PHUONG, DUNG NGUYEN THI TUYET, LAN LE THI TUYET Respiratory Outpatient Clinic, University Medical Center at Ho Chi Minh City, Ho Chi Minh City, Vietnam Introduction How will be the outcomes if GINA and GOLD are practically implemented at district-level health care centers in Ho Chi Minh City (HCMC)? Objective To estimate the proportion of totally controlled asthma, the proportion of improvement of 4 points in St. George scale, the proportion of noncompliance, and the direct health care cost in asthmatic and chronic obstructive pulmonary disease (COPD) patients managed according to GINA and GOLD. Methods 83 patients with asthma and 40 patients with COPD at Health Care Center of Hoc Mon District, Health Care Center of Phu Nhuan District, and Regional General Hospital of Thu Duc District were treated according to GINA and GOLD for 12 months. Clinical responses and pulmonary function characteristics, compliance and health care cost were evaluated. Results The proportion of asthmatic patients with totally controlled asthma was 31%. The proportion of COPD patients with improvement of 4 points in St. George scale was 50%. The proportion of noncompliance was 58% in asthmatic patients and 60% in COPD patients. Annual per-patient mean of direct health care cost was USD198 in asthmatic patients and USD330 in COPD patients. Conclusion Implementation of GINA and GOLD is feasible at district-level health care centers in HCMC. The proportion of asthmatic patients with totally controlled asthma and COPD patients with signicant improvement of quality of life is acceptable.

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A NEWER TREATMENT REGIME FOR ADULT ACUTE ASTHMATICS WITH INHALED IPRATROPIUM BROMIDE AND SALBUTAMOL IN MULTIPLE INTERMITTENT DOSES USING A VOLUMETRIC SPACER IN EMERGENCY SETTING MAMUNUR RASHID, MURTAZA KHAIR, ALI HOSSAIN, RASHIDUL HASSAN National Institute of Diseases of Chest and hospital, Mohakhali, Dhaka, Bangladesh Introduction Bronchial asthma is a common world-wide problem. It affects 7% of the population of the United States, 6.5% of British people and a total of 300 million worldwide1. In Bangladesh, about 7 million people are suffering from bronchial asthma (5.2% of total population)2. All patients with asthma are at risk of having exacerbations characterized by a progressive increase in shortness of breath, cough, wheezing or chest tightness, and by a decrease in expiratory airow that can be quantied by simple measures of pulmonary function such as the peak expiratory ow rate (PEFR) and FEV1. The severity of exacerbations may range from mild (FEV1 5080%) to life threatening (FEV1 < 30%)3. Beta2 agonists have been shown to be effective and are recommended as rst-line treatment for these acute episodes4. Ipratropium is a short-acting bronchodilator5 and its use in bronchial asthma in limited3. Various studies were conducted in different part of the world to dene its use in asthma. Here, we conducted this study to evaluate the effectiveness of combination of salbutamol and ipratropium bromide in multiple intermittent doses using a volumetric spacer in the treatment of adult patients with acute asthma (FEV1 3050%) in comparison with salbutamol alone. Methods This single-blind, randomized, controlled study was conducted in emergency department of National Institute Diseases of Chest and Hospital (NIDCH), Mohakhali, Dhaka, Bangladesh from July 2005 to June 2006. Adult patients (>14 years) with acute asthma (FEV1 3050%) who attended emergency department of NIDCH were enrolled consecutively in this study and were divided into two groups randomly using a random table. One group was treated with the inhalers leveled A which contain salbutamol and ipratropium bromide (100 gm salbutamol sulphate and 20 gm ipratropium bromide per puff) delivered by a volumetric spacer device at a rate of four puffs/10 minutes for 1 hours. Another group was treated with the inhalers leveled B which contain salbutamol (100 gm/puff) at a rate of 4 puff/10 minutes for same period. In this way, total 100 patients were enrolled, of those 51 patients were in IB group and 49 patients were in S group. Following variables were measured in each patient immediately before starting treatment and at 30 minutes interval thereafter for 1 hours. Forced Expiratory Volume in 1st second (FEV1), Peak Expiratory Flow (PEF), Saturation of oxygen (SO2), Respiratory rate (RR), Heart Rate (HT), Accessory muscles used, dyspnoea and wheeze were the variables that were recorded in a preformed questionnaire form. Unpaired T test was done for statistical analysis. Results Total 51 patients were in combination of salbutamol and ipratropium group (IB group) and 49 patients were in Salbutamol group (S group) among studied patients. There was no signicant difference in FEV1 (39.8% 4.8 vs 38.6 4.5), PEFR (137.2 32.8 L/min vs 127 32.04 L/min), SO2 (94.5% 2.8 vs 93.4% 2.3), Respiratory rate (34.7 4.6/min vs 33.4 3.7/min), Heart rate (112.5 13.2/min vs 105.8 12.2/min) between these two groups at pretreatment level. But after 30 minutes, FEV1 (60% 8.7 vs 49.1% 6.4), PEFR (186.4 40.1 L/min vs 146.7 36.3 L/min), SO2 (97.8% 1.0 vs 95.9% 1.8) were signicantly improved (p < 0.005) in IB group over S group and these improvement were maintained signicant at 60 minutes and 90 minutes. e was also signicant reduction of Respiratory rate and heart rate. Side-effect proles were minimal in both groups. Conclusion This study demonstrated that adult acute asthmatics can be effectively treated with repeated intermittent doses of combination ipratropium bromide and salbutamol by a volumetric spacer device. This simple, cheap, user-friendly regime can be a useful tool for the treatment of acute asthmatics especially in a resource-poor setting. References 1. Wikipedia. Asthma. Available from: http://en.wikipedia.org/wiki/Asthma [Accessed on July 2 2010]. 2. Hassan M R, Kabir MRML. Mahmood AM, Hossain MA et al. Self-reported asthma symptoms in children and adults of Bangladesh. Finding of First Asthma prevalence study in Bangladesh. Inter J Epidemiology 2002; 31: 1819. 3. National Guideline for Asthma, Bronchiolitis and COPD. Asthma Association, Dhaka, Bangladesh. 2001. 4. Rodrigo GJ and Rodrigo C. First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Care Med 2000; 161:18628. 5. Garrett JE, Town G I, Rodwell P, et al. Nebulized salbutamol with and without ipratropium bromide in the treatment of acute asthma. J Allergy Clin Immunolog, 1997; 100: 16570.

THE USE OF ASTHMA CONTROL TEST (ACT) AS AN ALTERNATIVE TOOL TO GINA CRITERION TO ASSESS ASTHMA CONTROL AMONG VIETNAMESE PATIENTS, 20082009 VINH NGUYEN Family Medicine, University of Medicine and Pharmacy, Hochiminh City, Vietnam Introduction Asthma is a burden chronic respiratory disease in Vietnam and its control now is lower than expected due to lack of tools to assess asthma control. The ACT is one of the tools which can be applied to improve asthma control; however, its validity is not yet determined in Vietnamese patients. Methods To determine the reliability and validity of the ACT as a means to detect GINA-dened not-controlled (partly- and un-controlled) asthma; and the agreement between ACT and GINA in classifying asthma control, a crosssectional study was done among 323 asthmatic out-patients 12 years old or older in Hochiminh City, Vietnam. Using ternary split of asthma control for both rating systems (GINA: uncontrolled, partly controlled and controlled asthma; and ACT score: 514, 1519 and 2025), Kappa coefcient of agreement and correctly classied rate between ACT and GINA were calculated. With binary split classication (GINA: not-controlled vs controlled asthma; and ACT: 519 vs 2025), ACT was validated by sensitivity, specicity, predictive values and area under the ROC curve in detecting GINA not-controlled asthma. Subgroup analysis was applied for asthma severity, gender and age. The responsiveness of ACT with doctors treatment modications and the relationship between ACT and FEV1, and ACT and PEF were also determined. Results Internal consistency of the ACT was 0.83 measured by Cronbachs alpha. Kappa coefcient of 0.55, based on the ternary spit, represents moderate agreement between the two rating systems and the correctly classied rate in this split was 75%. In binary split, the area under the ROC curve for ACT predicting GINA control was 0.85. To detect GINA not-controlled asthma, the ACT had sensitivity of 70%, specicity of 93%, positive predictive value (PV) of 89%, negative PV of 79%, positive likelihood ratio (LR) of 9.6, negative LR of 0.3 and correctly classied rate of 83% with a cut off point of 19. The validity of the ACT and the agreement of it and GINA were consistent across sexes but worst in adolescent or younger adults (35 years old) and in patients who had stage 1 or stage 4 asthma. The ACT score is signicantly correlated with %FEV1 (r = 0.35, p < 0.001) and with %PEF (r = 0.26, p < 0.001). Conclusion Vietnamese ACT is useful to identify outpatients with GINAdened not-controlled asthma.

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IMPACT OF OBESITY ON ASTHMA VK VIJAYAN, KUMAR R ANANDHA Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India Introduction Both obesity and asthma are common conditions, characterized by the presence of local and systemic inammation1 and the relationship between them is not well understood. The objective of the study was to compare pulmonary function tests and systemic inammatory marker [high sensitivity C-reactive protein (hs-CRP)] and local inammatory marker [fraction of nitric oxide in exhaled air (FeNO)] in non-obese and obese bronchial asthma patients. Methods The study was a cross-sectional study. A total of sixty bronchial asthma patients were taken for the study as per GINA guidelines, out of which thirty were non-obese bronchial asthma patients (n = 30), and thirty were obese bronchial asthma patients (n = 30). The selected patients underwent spirometry and estimation of hs-CRP in blood and fraction of nitric oxide in exhaled air (FeNO).2 Results The mean Body mass index (BMI) for the non-obese and obese group was 21.64 Kg/m2 and 34.1 Kg/m2 respectively (p = 0.001). There was signicant difference in functional residual capacity (FRC) (2.81 L vs 2.17 L, p = 0.002) and expiratory reserve volume (ERV) (1.24 L vs 0.77 L, p < 0.001) both being lower in the obese group. The values of non-obese and obese group for forced vital capacity (3.24 L vs 2.87 L, p = 0.10), forced expiratory volume in rst second (2.27 L vs 2.03 L, p = 0.24), total lung capacity (4.78 L vs 4.31, p = 0.11) and residual volume (1.42 L vs 1.32 L, p = 0.46) did not show any signicant difference in between the groups. The mean value of hs-CRP in non-obese and obese group was 3.01 mg/L and 4.07 mg/L respectively and the difference was not statistically signicant (p = 0.15). The mean value of FeNO in non-obese and obese group was 63.20 ppb (parts per billion) and 63.75 ppb respectively and the difference was not statistically signicant (p = 0.95). Conclusion Obesity does not appear to exacerbate the local and systemic inammatory responses in bronchial asthma. References 1. Sutherland TJ, Cowan JO, Young S, et al. The association between obesity and asthma: interactions between systemic and airway inammation. Am J Respir Crit Care Med 2008; 178: 46975. 2. American Thoracic Society, European Respiratory Society. ATS/ERS recommendations for standardized procedures for the online and ofine measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide. Am J Respir Crit Care Med 2005; 171: 91230.

THE DOSE OF INHALED STEROIDS IS NOT A RISK FACTOR FOR PNEUMONIA NENE KIDA, HIROYOSHI WATANABE, MAYUKO TANAKA, MASANORI WADA, MARI MIZUGUCHI, HIDEYUKI SATO, RYOSUKE SOUMA, GAKU IKEGAMI, HIRONORI SAGARA Department of Respiratory Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan Introduction Allergic airway inammation is characterized by inammatory cell inltration, involving eosinophils, T cells, neutrophils, and mast cells, and airway epithelial injury. Repeated episodes of allergic inammation induce airway remodeling, leading to irreversible limitations of airow and continuous airway hyperresponsiveness. Factors such as viral infections have an important role in the development of such inammation. The risk of bacterial infections such as pneumonia is also involved. In asthmatic patients, the dose of inhaled steroids increases in parallel to disease severity, which may also increase risk. Methods We examined whether the steroid dosage is a risk factor for pneumonia in patients with different severities of asthma based on prospective study from patients charts. Results Among inpatients with various severities of asthma, there was no correlation between disease severity and pneumonia. The rate of hospitalization for pneumonia did not differ signicantly among patients with different severities of asthma. We also examined the relation between the steroid dosage and hospitalization due to pneumonia, but there was no correlation between these variables. Conclusion Our results suggested that high-dose inhaled steroids, positioned as an important long-term treatment for asthma, can be used safely, without increasing the risk of pneumonia.

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ANTIGEN SPECIFIC IGG SUPPRESSES THE DENDRITIC CELLS RECEPTOR IIB IN ASTHMA ACTIVATION VIA FC YUMIKO ISHIKAWA, KOBAYASHI KAZUYUKI, YAMAMOTO MASATSUGU, NISHIMURA YOSHIHIRO Graduate School of Medicine, Kobe University Hospital, Chuo-ku, Kobe, Japan Introduction RIIB), which is expressed on many receptor IIB (Fc inammatory cells such as dendritic cells (DCs), macrophages, and granulocytes, is known to play important roles in the pathology of bronchial asthma. We have reported that antigen specic IgG ameliorates allergic airway inammation via RIIB on DCs in vivo. In this study, we examined the effect of antigen Fc specic IgG on the antigen presentation of BMDCs (bone marrow derived DCs) in vivo and vitro. Methods RIIB knockout) were asthmatic mice (Wild Type and Fc sensitized by OVA/alum and were administered intratracheally some subclasses of anti OVA IgG before the OVA challenge. The effect of anti OVA IgG was analyzed by total cells and eosinophils in the BALF, airway hyperresponsiveness and histology. To verify the role of anti OVA IgG and DCs, every mouse was compared about uptaking of uorescene-labelled OVA into lymph nodes in immunohistochemistry and the expression of MHC class II on DCs by ow cytometry. In vitro, BMDCs from WT mice were incubated for 48 hours with OVA peptide and OVA specic CD4 T cells. To evaluate the activation of DCs veried by anti OVA-IgG1, the number of increasing T cells was measured by a colorimetric assay using the WST-8 cell-counting kit. Finally, BMDCs were RIIB KO mice and the effect of anti OVA-IgG1 was analyzed by transplanted to Fc BALF. Results Anti OVA-IgG1 ameliorated asthmatic phenotype, inammatory cells invasion in BALF (total cells; IgG1 7.66 1.52, IgG2a 19.6 6.26, PBS 53.2 15.4/L, eosinophils; IgG1 1.36 0.97, IgG2a 11.9 5.46, PBS 44.6 14.9/L), histology and airway hyperresponsiveness, compared to anti OVAIgG2a. Fluorescence microscopy ndings showed the reduction of OVA transport into lymph nodes by anti OVA-IgG1 treatment. The expression of MHC class II on DCs was reduced by anti OVA-IgG1 treatment in ow cytometry. In vitro, the proliferation of T cells showed statistically signicant differences by anti OVA-IgG1 treatment (treatment v.s. non-treatment; 0.10 v.s. 0.44). Anti OVA-IgG1 RIIB KO mice. Fc was deteriorated allergic airway inammation in Fc mice transplanted of BMDCs from wild type mice ameliorated allergic airway inammation by anti OVA-IgG1 treatment. Conclusion This study suggests that antigen specic IgG ameliorates RIIB on DCs. Allergic airway inammation via Fc.

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CORRELATION BETWEEN PERCUTANEOUS OXYGEN SATURATION AND THE ASTHMA SEVERITY PARAMETERS IN ASTHMATIC PATIENTS DURING ACUTE EXACERBATION ISNIN ANANG MARHANA, MUHAMMAD AMIN, LAKSMI WULANDARI, SLAMET HARIADI, YUSUF WIBISONO Pulmonology Department, Dr. Soetomo Teaching Hospital, Airlangga University School of Medicine, Surabaya, Indonesia Introduction One of the severity parameter in acute asthma exacerbation according to GINA criteria (2008) is oxygen saturation. Percutaneous oxygen saturation is a cheap, noninvasive method to assess oxygenation. The correlation between percutaneous oxygen saturation with other variables from GINA criteria has yet to be conrmed. Methods A total of 43 subjects with acute asthma exacerbation attending Dr. Soetomo General Hospital Emergency Department from April to October 2009 were enrolled to this study. All of the subjects were interviewed and undergone thorough physical examination, blood gas analysis, and oxygen saturation measurement. Results According to GINA criteria, there were on mild (39.5%), moderate (44.2%), and severe (11.6%) asthma exacerbation. Other 4.7% were in respiratory arrest imminent state. There were good correlation between percutaneous oxygen saturation and the degree of exacerbation severity (r = 0.871, p < 0.0001). It also correlated well with respiratory rate (r = 0.772, p < 0.0001); dyspnea (r = 0.605, p < 0.0001); PaO2 (r = 0.764, p < 0.0001); pCO2 (r = 0.732, p < 0.0001); post bronchodilator PEFR (r = 0.704, p < 0.0001). Weak correlation were found with the accessory muscles and suprasternal retraction (r = 0.492, p < 0.001); wheezing (r = 0.492, p < 0.005); pulse rate (r = 0.210; p = 0.172); and pulsus paradoxus (r = 0.129, p = 0.405). Conclusion Percutaneous oxygen saturation was strongly correlated with the degree of asthma exacerbation severity, respiratory rate, and PaO2. Therefore it may be used to non-invasively assess the degree of asthma exacerbation severity, especially in health care facilities which do not have the equipment to perform blood gas analysis.

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PREVALENCE OF ASTHMA IN A GROUP OF 1314 YEARS OLD STUDENTS USING THE ISAAC WRITTEN QUESTIONNAIRE IN JAKARTA FENI FITRIANI, FAISAL YUNUS, MENALDI RASMIN, DIANIATI K SUTOYO, WIWIEN H WIYONO, BUDHI ANTARIKSA, RATNAWATI RATNAWATI Persahabatan Hospital, Jakarta, Indonesia Introduction Prevalence of asthma in children in Indonesia varies from 2.1% to 32.2% depends on location of the study and method of study (questionnaire vs bronchoprovodation testing). This study using the ISAAC (International Study of Asthma and Allergies in Childhood) written questionnaire to measure asthma prevalence in 1314 years old students in Jakarta, Indonesia. Methods The ISAAC questionnaire were distributed randomly in 2008 at 71 Junior High Schools in Jakarta. Informed consent were taken before the procedure. The result will be compare with the data of The ISAAC questionnaire were distributed randomly in 2001 at 57 junior high schools in Jakarta. Results There were 10 275 students in 2008 and 2234 Junior high school student in 2001, age 1314 years old in Jakarta were submitting the ISAAC questionnaire. There was a increase in prevalence of asthma from 11.5% in 2001 to 12.2% in 2008. The prevalence of rhinitis increase from 10.6% in 2001 to 28.2% in 2008 and prevalence of eczema also increase from 2.9% in 2001 to 4.23% in 2008. Conclusion There has been increase in prevalence of asthma, rhinitis and eczema in Jakarta student.

ASSOCIATION BETWEEN AIR POLLUTION, ASTHMA AND ALLERGIES IN SCHOOLCHILDREN MOHAMMED SHAMSSAIN, WALID AL QEREM, KENNETH MCGARRY, LEILA NESHAT Department of Pharmacy, Health and Wellbeing, Faculty of Applied Medicine, University of Sunderland, Sunderland, United Kingdom Introduction Studies have demonstrated that air pollution is associated with exacerbation of asthma symptoms in children with asthma. Little is known about the susceptibility of subgroups, particularly those with atopy. There has been little study of effects of trafc exposure at school on new-onset asthma. Our intention is to evaluate the impact of air pollution on asthma and allergies in schoolchildren and to evaluate if identiable subgroups of asthmatic children are more likely to wheeze with exposure to ambient air pollution. Methods We studied two groups of schoolchildren, boys and girls, 1000 children from each group; one from a highly polluted area of inner city Cairo and the other from low polluted area of Shbeen Al Koom in the Delta. Forced vital capacity (FVC), forced expiratory volume (FEV1), peak expiratory ow rare (PEFR0 were measured by the Vitalograph spirometer. We used the Arabic version of ISAAC questionnaire (the International Study of Asthma and Allergies in Childhood). Questions about pet ownership have been added to ISAAC questionnaire. Air pollution monitoring has been performed from the Government sites. Results Mean SO2, NO2, Ozone, CO and PM10 in Cairo were 39.0 g/m3, 62.8 g/m3, 93.0 g/m3, 3.0 mg/m3, and 263.5 g/m3, respectively, while in Shbeen Al Koom were 17.0, 55.8, 28.0, 1.3, and 94.0, respectively. FVC, FEV1 and PEFR in Cairo were 1.99 l, 1.70 l, and 204.4 l/min, respectively, while in Shbeen AlKoom were 2.03, 1.79, and 207.4, respectively. Prevalence rates of Wheeze ever, current wheeze, asthma ever, rhinitis ever, hay fever and eczema ever in Cairo were 10.5%, 6.9%, 3.3%, 24.2%, 9.5%, and 8.1%, respectively, while in Shbeen Al Koom, they were 9.2%, 5.6%, 5.5%, 17.9%, 6.4%, 5.6%, respectively. There was signicant differences in the annual average concentrations of all pollutants, lung function tests, hospital admission rates and cases of diagnosed asthma between Cairo and Shbeen Al Koom. Conclusion The present study shows that air pollution is associated with increased risk of asthma and allergies. Children with atopy to cat and boys with asthma were the subgroups for which the largest associations were observed. Of the pollutants measured, PM10 appears to be the most important. Trafc-related pollution exposure contributes to the development of asthma.

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PREVALENCE OF OBSTRUCTIVE SLEEP APNEA (OSA) AMONG ASTHMA PATIENTS BASED ON CLINICAL SYMPTOMS (BERLIN QUESTIONAIRE) AND POLYSOMNOGRAPHY PUJI ASTUTI, FAISAL YUNUS, BUDHI ANTARIKSA, RATNAWATI Department of Pulmonology and Respiratory Medicine, Faculty of Medicine University of Indonesia, Jakarta, Indonesia Introduction Survey study focused on respiratory disorders show decreased sleep quality in asthma patients. Nocturnal asthma symptoms disturb sleep quality in some asthma patients, also other symptom such as snoring sometimes found in this population. Snoring and sleeplessness at daytime also commonly found in OSA patient. Recent study show that OSA is related to brochial hyperresponsiveness and as a trigger of asthma exacerbation. Methods In this observational case control study, data sampling were collected consecutively in all asthmatic patients (intermittent, mild persistent and severe persistent) from May 2009 to February 2010 in Persahabatan hospital Jakarta. Basic lung function/ spirometry; bronchial provocation test (3% Normal Saline) were done to all patients. The magnitude of OSA were evaluated by Berlin Questionnaire and polysomnogrphy. Additional anatomical evaluation releted to OSA/asthma risk factor-comorbid were done by ENT specialist. Results OSA was found in 20 (19.8%) out of 101 asthma patients. The main OSA symptoms found in asthma patients were snorring (100%), fatique after sleep (80%), sleeplesness at day time (25%). OSA patient has higher BMI (28,05kg/m2 vs 22,38kg/m2 in nonOSA); bigger neck sircumference (OSA 37,60 cm vs 33,62 cm in non OSA), decrease FEV1 (OSA: 56,70%pred vs non OSA 59,51%pred). Further evaluation are underway to evaluate related anatomical disorder and polysomnography. Conclusion Asthma patients have higher prevalence of OSA (19,80%) compare to the general population. The risk of OSA in asthma are correlated with increased BMI, neck circumstances and decreased FEV1. The main OSA symptom found in asthma patient is snorring (100%).

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LOW-, MEDIUM-, AND HIGH-DOSE MOMETASONE FUROATE/FORMOTEROL IMPROVES LUNG FUNCTION IN PERSISTENT ASTHMATICS ELI O MELTZER1, ROBERT A NATHAN2, STEVEN F WEINSTEIN3, HENDRIK NOLTE4 1 Allergy and Asthma Medical Group and Research Center, San Diego, CA, 2Asthma and Allergy Associates and Research Center, Colorado Springs, CO, 3Allergy & Asthma Specialists Medical Group, Huntington Beach, CA, and 4Merck Research Laboratories, Kenilworth, NJ, USA Introduction We evaluated lung function outcomes in persistent asthma subjects receiving mometasone furoate/formoterol (MF/F), a new inhaled corticosteroid (ICS)/long-acting 2-agonist (LABA) combination. Methods Three phase III, randomized, multicenter, double-blind studies were conducted in moderate-to-severe asthma subjects previously receiving ICS LABA therapy: 1) study P04073: MF/F(100/10 g), MF(100 g), F(10 g), and placebo (n = 182, n = 188, n = 188, n = 188, respectively; 26 weeks; 23 week active run-in MF[100 g]); 2) study P04334: MF/F(200/10 g), MF(200 g), F(10 g), and placebo (n = 191, n = 192, n = 202, n = 196, respectively; 26 weeks; 23 week active run-in MF[200 g]); 3) study P04431: MF/F(400/10 g), MF/F(200/10 g), and MF(400 g) (n = 255, n = 233, n = 240, respectively; 12 weeks; 23 week active run-in MF[400 g]). All doses were twice-daily. Area under the curve from 012 hours for the change from baseline to week-12 in forced expiratory volume in 1 second (FEV1AUC0-12h) and change from baseline in combined morning/evening (AM/PM) peak expiratory ow (PEF) at week-12 and study endpoint were assessed. Results Week-12 FEV1AUC0-12h was signicantly higher for: MF/F(100/10 g) versus MF(100 g) and placebo (4.00 vs 2.53 and 1.11 Lxh, respectively, P 0.001) in study P04073; MF/F(200/10 g) versus MF(200 g), F(10 g), and placebo (3.11 vs 1.30, 1.93, and 0.57 Lxh, respectively, P 0.017) in study P04334; and MF/F(200/10 g) and MF/F(400/10 g) versus MF(400 g) (3.59 and 4.19 vs 2.04 Lxh, respectively, P < 0.001) in study P04431. Change from baseline in week-12 and endpoint AM/PM PEF was signicantly higher for: MF/F(100/10 g) versus MF(100 g), F(10 g), and placebo (week-12: 5.3% vs 1.6%, 2.6%, and 2.4%, respectively, P 0.007; endpoint: 4.4% vs 0.3%, 0.7%, and 5.5%, respectively, P < 0.001) in study P04073; MF/F(200/10 g) versus MF(200 g), F(10 g), and placebo (week12: 6.9% vs 2.6%, 1.3%, and 3.3%, respectively, P < 0.001; endpoint: 5.9%; vs 1.5%, 3.5%, and 6.6%, respectively, P 0.003) in study P04334; and MF/F(200/10 g) and MF/F(400/10 g) versus MF(400 g) (week-12: 11.5% and 13.4% vs 7.0%, respectively, P 0.003; endpoint: 11.8% and 12.6% vs 6.6%, respectively, P < 0.001) in study P04431. Conclusion Three different MF/F doses signicantly improved lung function outcomes compared with MF, F, and placebo in moderate-to-severe persistent asthmatics.

MOMETASONE FUROATE/FORMOTEROL IMPROVES ASTHMA CONTROL IN SUBJECTS WITH UNCONTROLLED PERSISTENT ASTHMA MARTHA WHITE1, HENDRIK NOLTE2, ELI O MELTZER3, ROBERT A NATHAN4 1 Insititute for Asthma & Allergy, Wheaton, MD, 2Merck Research Laboratories, Kenilworth, NJ, 3Allergy and Asthma Medical Group and Research Center, San Diego, CA, and 4Asthma and Allergy Associates and Research Center, Colorado Springs, CO, USA Introduction We assessed asthma control in subjects with persistent asthma receiving treatment with mometasone furoate/formoterol (MF/F), a newlydeveloped inhaled corticosteroid (ICS)/long-acting 2-agonist combination, administered via a pressurized metered-dose inhaler. Methods Three double-blind, randomized, phase III, multicenter studies assessed MF/F(100/10 g), MF/F(200/10 g), or MF/F(400/10 g) in asthma subjects previously receiving ICS: 1) study P04073 (26 weeks; 23-week-runin MF[100 g]): MF/F(100/10 g; n = 182), MF(100 g; n = 188), F(10 g; n = 188), and placebo (n = 188); 2) study P04334 (26 weeks; 23-week-run-in MF[200 g]): MF/F(200/10 g; n = 191), MF(200 g; n = 192), F(10 g; n = 202), and placebo (n = 196); 3) study P04431 (12 weeks; 23-week-run-in MF[400 g]): MF/F(400/10 g; n = 255), MF/F(200/10 g; n = 233), and MF(400 g; n = 240). Doses were twice-daily. Key secondary endpoints of each study included mean Asthma Control Questionnaire (ACQ) scores at: week-4, week-12, and study endpoint (P04073/P04334); and week-4 and study endpoint (P04431). Least squares (LS) mean score changes from baseline were calculated using analysis of covariance. A 0.5-point change in ACQ score was considered clinically relevant (minimal important difference [MID]). Results In study P04073, LS-mean ACQ score changes were signicantly better for MF/F(100/10 g) versus: MF(100 g), F(10 g), and placebo at week-4 (0.35 vs 0.20, 0.07, and 0.07, respectively) and week-12 (0.43 vs 0.22, 0.12, and 0.06, respectively); and F(10 g) and placebo at endpoint (0.36 vs 0.07 and 0.24, respectively; MID achieved for MF/F vs placebo) (P 0.023). Study P04334 LS-mean score changes were signicantly better for MF/F(200/10 g) versus: F(10 g) and placebo at week-4 (0.34 vs 0.04 and 0.05, respectively); MF(200 g), F(10 g), and placebo at week-12 (0.45 vs 0.22, 0.12, and 0.04, respectively); and MF(200 g), F(10 g), and placebo at endpoint (0.40 vs 0.23, 0.11, and 0.14, respectively; MID achieved for MF/F vs placebo) (P 0.026). Study P04431 LS-mean score changes were signicantly better for both MF/F(200/10 g) and MF/F(400/10 g) versus MF(400 g) at week-4 (0.43 vs 0.46, 0.24, respectively) and endpoint (0.56 vs 0.51, 0.33, respectively; MID achieved in both MF/F groups) (P 0.008). Conclusion MF/F was more effective in controlling asthma than MF, F, and placebo at most time points.

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TREATMENT OF PERSISTENT ASTHMA WITH MOMETASONE FUROATE/FORMOTEROL COMBINATION THERAPY IS ASSOCIATED WITH A LOW INCIDENCE OF ORAL CANDIDIASIS AND DYSPHONIA STEVEN WEINSTEIN1, ROBERT A NATHAN2, ELI MELTZER3, HENDRIK NOLTE4, JORGE MASPERO5 1 Allergy & Asthma Specialists Medical Group, Huntington Beach, CA, USA, 2 Asthma and Allergy Associates and Research Center, Colorado Springs, CO, USA, 3Allergy and Asthma Medical Group and Research Center, San Diego, CA, USA, 4Merck Research Laboratories, Kenilworth, NJ, USA, and 5 Fundacin Cidea, Allergy and Respiratory Research Unit, Buenos Aires, Argentina Introduction Dysphonia and oral candidiasis are 2 local adverse events (AEs) commonly associated with inhaled corticosteroid (ICS) use. We assessed the incidence of these 2 AEs by analyzing data from 6 phase III studies of mometasone furoate/formoterol (MF/F) administered via a pressurized metered-dose inhaler (MDI), an investigational ICS/long-acting 2-agonist combination product. Methods Incidences of dysphonia and oral candidiasis were assessed in all 6 phase III MF/F persistent asthma trials conducted to date: 1) study P04703: n = 343, 4 weeks, open-label, 2-week compliance period on MF/F[100/10 g], MF/F = 100/10 g; 2) study P04705: n = 722, 12 weeks, open-label, 24-week run-in on MF[200 g], MF/F = 200/10 g, uticasone propionate/salmeterol dry powder inhaler (FP/S-DPI) = 250/50 g; 3) study P04431: n = 728, 12 weeks, double-blind, 24-week run-in on MF[400 g], MF/F = 200/10 g, MF/F = 400/10 g, MF = 400 g; 4) study P04073: n = 746, 26 weeks, double-blind, 23-week run-in on MF[100 g], MF/F = 100/10 g, MF = 100 g, F = 10 g, placebo; 5) study P04334: n = 781, 26 weeks, double-blind, 23-week run-in on MF[200 g], MF/F = 200/10 g, MF = 200 g, F = 10 g, placebo; 6) study P04139: n = 404, 52 weeks, open-label, MF/F = 200/10 g, MF/F = 400/10 g, FP/S-MDI = 250/50 g, FP/S-MDI = 500/50 g. All subjects (12 years) received twice daily (BID) treatment. All studies were approved by an institutional review board, and all subjects provided informed consent. Results Incidences of treatment-emergent dysphonia in each treatment group were: study P04703: MF/F[100/10 g] = 0.3%; study P04705: MF/F[200/10 g] = 3.8%, FP/S-DPI[250/50 g] = 3.7%; study P04431: MF/F[200/10 g] = 0%, MF/F[400/10 g] = 0.8%, MF[400 g] = 1.3%; study P04073: MF/F[100/10 g] = 0.6%, MF[100 g] = 0.5%, F[10 g] = 0.5%, placebo = 0.5%; study P04334: MF/F[200/10 g] = 1.0%, MF[200 g] = 0.5%, F[10 g] = 0.5%, placebo = 0.5%; study P04139: MF/F[200/10 g] = 5.0%, MF/F[400/10 g] = 3.8%, FP/S-MDI[250/50 g] = 7.4%, FP/S-MDI[500/50 g] = 3.1%. Incidences of treatment-emergent oral candidiasis in each treatment group were: study P04703: MF/F[100/10 g] = 2.0%; study P04705: MF/F[200/10 g] = 0%, FP/S-DPI[250/50 g] = 0.9%; study P04431: MF/F[200/10 g] = 0.4%, MF/F[400/10 g] = 0.8%, MF[400 g] = 0.8%; study P04073: MF/F[100/10 g] = 0.5%, MF[100 g] = 0.5%, F[10 g] = 0%, placebo = 0%; study P04334: MF/F[200/10 g] = 1.0%, MF[200 g] = 0.5%, F[10 g] = 1.0%, placebo = 0.5%; study P04139: MF/F[200/10 g] = 1.4%, MF/F[400/10 g] = 0.8%, FP/S-MDI[250/50 g] = 1.5%, FP/S-MDI[500/50 g] = 3.1%. Conclusion Data from 6 clinical trials indicate that the incidences of dysphonia and oral candidiasis associated with the three MF/F dosing strengths investigated are comparable to those observed with standard doses of MF, F, and FP/S. No dose relationship with respect to these AEs and MF/F was observed.

THE EFFECT OF MOMETASONE FUROATE/FORMOTEROL COMBINATION TREATMENT ON SEVERE EXACERBATIONS REQUIRING HOSPITALIZATION, EMERGENCY TREATMENT, OR SYSTEMIC CORTICOSTEROID TREATMENT: RESULTS FROM TWO RANDOMIZED, PLACEBO-CONTROLLED STUDIES ROBERT A NATHAN1, ELI O MELTZER2, HENDRIK NOLTE3 1 Asthma and Allergy Associates and Research Center, Colorado Springs, CO, USA, USA, 2Allergy and Asthma Medical Group and Research Center, San Diego, CA, USA, and 3Merck Research Laboratories, Kenilworth, NJ, USA Introduction We investigated the effect of mometasone furoate/formoterol (MF/F), a newly developed ICS/LABA, on the incidence of severe asthma exacerbations (ie, asthma deteriorations). Methods Data from two phase III, double-blind, multicenter, placebo-controlled studies comparing MF/F(100/10 g) versus MF(100 g), F(10 g), or placebo (n = 182, n = 188, n = 188, n = 188, respectively; 26 weeks; 23 week active run-in MF[100 g]) and MF/F(200/10 g) versus MF(200 g), F(10 g), and placebo (n = 191, n = 192, n = 202, n = 196, respectively; 26 weeks; 23 weeks active run-in MF[200 g]) were analyzed to investigate MF/Fs ability to reduce severe exacerbations in subjects (12 years) with moderate asthma. Time-to-rst severe exacerbation (coprimary study end point; dened as clinically judged deterioration [ie, emergency treatment, hospitalization, or treatment with additional medication]; decrease in forced expiratory volume in 1 second >20% from baseline; or decrease in peak expiratory ow >30% from baseline for 2 consecutive days) was characterized. Results After 26 weeks of treatment, MF/F(100/10 g) signicantly reduced the incidence of severe exacerbations (16.5%) versus 28.2%, 44.7%, and 45.7% in the MF(100 g), F(10 g), and placebo groups, respectively (P 0.006), resulting in an increased time-to-rst exacerbation for MF/F(100/10 g)-treated subjects. No subjects were hospitalized; 3 required emergency treatment (F[10 g], n = 2; placebo, n = 1); and 41 required systemic corticosteroids (MF/F[100/10 g], n = 3; MF[100 g], n = 4; F[10 g], n = 15; placebo, n = 19). Similarly, in the MF/F(200/10 g) study, the incidence of severe exacerbations was lowest for MF/F(200/10 g)-treated subjects (30.4%) versus 33.9%, 54.0%, and 55.6% in the MF(200 g), F(10 g), and placebo groups, respectively (P < 0.001 vs F[10 g] and placebo), resulting in an increased time-to-rst exacerbation for MF/F(200/10 g)- versus F(10 g)and placebo-treated subjects. Three subjects were hospitalized (MF/F[200/10 g], MF[200 g], and F[10 g], n = 1); 10 required emergency treatment (MF[200 g], n = 1; F[10 g], n = 5; placebo, n = 4); and 46 required systemic corticosteroids (MF/F[200/10 g], n = 2; MF[200 g], n = 5; F[10 g], n = 20; placebo, n = 19). Conclusion Treatment with MF/F(100/10 g) or MF/F(200/10 g) twice-daily resulted in signicant reductions in the incidence of severe exacerbations in patients with moderate inadequately controlled asthma.

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PERSONALITY CHARACTERISTICS OF ASTHMATIC PATIENTS WITH POOR OR WEAK COMPLAINTS ANALYZED BY TOKYO UNIVERSITY EGOGRAM (TEG) IN JAPAN MATSUNUMA RYO, OHKUNI YOSHIHORO, KOMATSU AKINA, NAKASHIMA KEI, ANDO KATSUTOSHI, ASAI NOBUHIRO, HASEGAWA KEIKO, MISAWA MASAHUMI, KANEKO NORIHIRO Respiratory Medicine, Kameda Medical Center, Kamogawa City, Chiba, Japan Introduction Patients with severe asthma (experiencing previous hospital admissions and/or daily symptoms) have occasionally been seen with poor or weak complaints. Several studies have analyzed the psychiatric status of the patients with severe asthma, but few studies have dealt with the relevance of the personality characteristics of the patients with the severity of their asthma. Methods To assess the relevance of the personality characteristics with the severity of hospitalized asthmatic patients who tend to complain poorly, and those with strong complaints who had never been hospitalized because of asthma exacerbation or dropped out of the outpatient clinic visit, the authors interviewed 21 patients who were hospitalized between November, 2008 and February, 2010. A control group of 23 asthmatic patients who have never been admitted to the hospital or dropped out of the outpatient clinic visit were enrolled. After a baseline assessment, the patients underwent an interview concerning their personal and family psychiatric history and a psychodiagnostic investigation using Tokyo university egogram (TEG) and Yatabe-Guilford test (YG test). Results While 16 patients (80%) in the group of the 21 poorly complaining patients discontinued outpatient clinic visit and thus treatment, no patients with good complaints did so. No signicant differences in the results of psychodiagnostic tests between the patients with poor complaints and those with good complaints were observed. Psychiatric history was similar in the two groups. Conclusion Our results suggest that personality characteristics are not related to the hospitalization because of asthma exacerbation or the discontinued treatment.

RELATIONSHIP BETWEEN METEOROLOGICAL FACTORS AND ASTHMA EXACERBATION (RETROSPECTIVE STUDY) RESTI YUDHAWATI, WINARIANI Department of Pulmonology, Airlangga School of Medicine, Dr. Soetomo Teaching Hospital, Surabay, Indonesia Background Bronchial asthma is one of the typical weather disease, which attacks and meteorological factors are very closely related. There is evidence that asthma exacerbation is related to seasonal and meteorological factors, and there has been considerable debate about the possible role of various environmental factors in explaining geographical patterns in asthma. It is therefore reasonable to hypothesize that climate may affect asthma exacerbation, either directly (for example, via an effect of air temperature on airway responsiveness), or indirectly (for example, via altered exposure to infections, aeroallergens, or air pollutants). In this study, we investigated the hypothesis that meteorological factors have a role in the regional differences in adult asthma exacerbation in Surabaya. Methods Retrospective Observational study. We studied the relationship between meteorological factor (temperature, relative humidity, rainfall and atmospheric pressure) and asthma exacerbation during a 4-year period (January 1, 2000December 31, 2004) in the Pulmonary ward of Dr. Soetomo Hospital, Surabaya. Results Out of 502 cases of asthma exacerbation, there are 312 female patients (62.15%) and 190 are male (37.85%). Most of the patients aged 1423 years old (26.1%). Average of climate changes during a 4-year period are: temperature +28.76oC, air pressure = 1010, 82 mbar; humidity +74.2%; rainfall = 154.22 mm. The relationship between the occurrence of asthma exacerbation and climate change were analyzed with Pearson Correlation Test. P Value of <0.05 was considered to be signicant. Conclusion There were signicantly associated the occurrence of asthma exacerbation between relative humidity and rainfall.

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THE SENSITIVITY AND SPECIFICITY OF ASTHMA CONTROL TEST ARDESHIR BANIKARIMI, KAZEM KAZEMNEJAD Faculty Member, Medical University, 101 Edalat aAve-Naharkhoran St., Gorgan City, Iran Introduction Asthma guidelines indicate that the goal of treatment should be optimum asthma control. In a busy clinic practice with limited time and resources, there is need for a simple method for assessing asthma control with or without lung function testing. The development of the Asthma Control Test (ACT), a short, simple, patient-based tool for identifying patients with poorly controlled asthma, was recently described in patients under the routine care of an asthma specialist. Methods The ACT was applied to patients 12 years of age or older attending an asthma clinic. In the waiting room, a physician explained each of the ve questions of ACT and then patients lled up the survey. A total of 25 points indicates complete control, from 20 to 24 points good. Results Our data show that the sensitivity, specicity, Positive predictive value and Negative predictive value of ACT for severe asthma are 94%, 71%, 90%, 83%. Conclusion The ACT is reliable, valid, and responsive to changes in asthma control over time in patients new to the care of asthma specialists.

SMOKING EXACERBATES AIRWAY INFLAMMATION IN PATIENTS WITH ASTHMA IKEGAMI GAKU, SEKI RISAKO, WATANABE HIROYOSHI, KIDA NENE, TANAKA MAYUKO, WADA MASANORI, MIZUGUCHI MARI, WAKAYAMA TOMOSHIGE, AKASAKA KEIICHI, FUEKI NAOTO, SAGARA HIRONORI Department of Respiratory Medicine, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan Introduction Environment factors such as passive smoking most likely play an important role in the onset and exacerbation of asthma. The mechanism is thought to involve the production of inammatory cytokines in response to smoke in the airway, with resultant changes in inammatory cells. Smoking is also linked to resistance to therapy caused by decreased adherence to treatment and reduced effectiveness of inhaled steroids. Smoking is thus implicated in the exacerbation of asthma, as well as increased refractoriness to therapy. Method We assessed exhaled nitric oxide level in patients with asthma to evaluate the correlation between airway inammation and smoking. Results The exhaled nitric oxide concentration was highly increased in current smokers with asthma, next highest in past smokers, and lowest in nonsmokers. Asthma control tests were performed to calculate asthma symptom scores. In contrast to exhaled nitric oxide concentrations, the score was highest in non-smokers. Conclusion These results show that smoking has a marked impact on asthma. Given that patients with asthma have high mortality and frequently present at emergency outpatient clinics, promotion of smoking cessation is an important issue not only for patients, but also for society as a whole.

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COMPARISON OF INTRAVENOUS HYDROCORTISONE VERSUS INHALED FLULTICASONE IN ADULT ACUTE ASTHMA A RANDOMIZED CONTROLLED TRIAL JENNYLYN GO, ERIC ONG, ABNER KOH Section of Pulmonary Medicine, Department of Medicine, Chinese General Hospital and Medical Center, Philippines Introduction Inhaled uticasone in acute bronchial asthma had been compared to other inhaled corticosteroids in terms of efcacy. Direct comparison of inhaled steroids with the intravenous forms are warranted since this is common practice. Methods All adults 18 to 60 years old, with known bronchial asthma regardless of severity of disease classication and severity of disease presenting at the emergency room, with informed consent were recruited. Excluded were status asthmaticus, those with chronic obstructive pulmonary disease and with steroid intake for the past two weeks. Patients randomized to intervention received inhaled uticasone via an ultrasonic nebulizer every 15 minutes together with inhaled short acting beta agonists (SABA), while those to control received 250 mg/mL of intravenous hydrocortisone single dose plus SABA. Outcomes assessed included baseline comparability in terms of demographic and clinical factors including vital signs, presence of wheezes, respiratory rate, oxygen saturation, baseline peak expiratory ow rate (PEFR). and mean rate of change in PEFR post-intervention. All measures of efcacy were pegged at .05 alpha level of signicance. Results A total of 16 subjects received the inhaled uticasone while 17 had intravenous hydrocortisone. The groups were comparable in terms of demographic variables however, the except for oxygen saturation and steroid use at baseline. Within groups analysis showed a statistically signicant increase in post-intervention mean percentage change in PEFR from baseline. (% change = 34.5% with inhaled versus IV steroids = 28.2%, p = .002; p <.001 respectively). Between groups comparison showed statistically higher PEFR absolute values in those using systemic steroids (182 versus 142 L/min, p = .047). Inhaled steroids had a higher likelihood for oxygen therapy (RR = 5.31, 95% CI 1.3720.6, p = .002); and chances of admission (RR = 4.0, 95% CI, 1.3911.5, p = .001). No signicant difference in vital signs, respiratory rate and oxygen saturation. Conclusion Fluticasone in the acute management of adult asthma produces comparable effects on the mean change in PEFR when compared to intravenous hydrocortisone despite its slow onset of action.
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THE EFFECT OF DNA VACCINE DURING CHEMOTHERAPY ON RAPIDITY OF ELIMINATION OF MYCOBACTERIUM TUBERCULOSIS IN INFECTED MICE SEUNG-EUN LEE, YUN-SEONG KIM, DU-SU CHEON, WOO-HYUN CHO, JI-EUN KIM, KI-UK KIM, HAE-KYUNG PARK, MIN-KI LEE, SUN-KYU PARK Respirology & Allergy Department, Yangsan Busan National Univ. Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, Korea Introduction Tuberculosis (TB), which is caused by Mycobacterium tuberculosis (M. Tb), is responsible for more than 2 million deaths each year. But, current chemotherapy cannot lead to complete elimination of TB and the overall protective effect of BCG against the development of TB in adults is 50%. We investigated the effect of Ag85B DNA vaccine during chemotherapy on rapidity of elimination of M. TB in lung and spleen. Methods Mice were treated with isoniazid and rifampin for 5 weeks from 4 weeks after aerosol infection with M. Tb Erdman. During this period of chemotherapy, DNA immunization was performed 3 times biweekly with an antigen 85B or empty vaccine. Results Bacterial numbers (log10 CFU) of DNA vaccinated group in spleen were 0.91 1.18, 0.85 1.01 after 3 weeks and 5 weeks of treatment, respectively and 2.24 0.89, 1.67 0.20 in empty group. But, this decrease didnt observed in bacterial counts of lung, nor did 7 weeks after completion of treatment in lung and spleen. Conclusion More rapid elimination of bacterial counts in spleen was observed in DNA vaccinated group than empty group, but faded away after completion of treatment. Ag 85B DNA vaccine may be effective to control systemic infection by M. Tb during chemotherapy, but it was not effective in local control.

FACTORS CONTRIBUTE TO HIGH TUBERCULOSIS MORTALITY IN CHANGHUA DISTRICT YI-WEN HUANG, YEN-PO YEH, JEN SUO, CHING-HSIUNG LIN, CHANG-SHENG LIN Changhua Hospital, No. 80, Sec 2, Zhongzheng Rd., Puxing Town, Changhua County, Taiwan R.O.C. Introduction Tuberculosis (TB) is an airborne infectious disease that is still a major issue due to its high prevalence in some countries. From the Taiwan Tuberculosis Control Report, the number of people who died from tuberculosis in 2005 and 2006 was 4.3 and 3.6 cases per 100 000 population respectively.1,2 This showed a signicant decrease in the tuberculosis death and led to the top 13 main causes of death in Taiwan.1,2 However, the tuberculosis mortality rate in Changhua district had increased from 22.0% to 24.8% in 20052006.2,3 This is one of the main causes for the overall low successful tuberculosis treatment rate in Taiwan. The aims of the study were to investigate the causes for the high tuberculosis death in Changhua district in order to improve success in treatment and reduce mortality. Methods Medical records of people who had conrmed tuberculosis and died between 2005 and 2006 were reviewed and related variables were analyzed to nd out the main factor contributing to the tuberculosis deaths. Results A total of 442 cases were included in the study. More than 80% of the deaths occurred in subjects older than 75 years old in Changhua. Twentyfour percent of the subjects reported as TB after death, and the average treatment days for TB death were 38 days which indicated a delay of diagnosis and/or treatment. The majority of subjects (59.1%) had at least one comorbidity and this had contributed to more fatalities than tuberculosis. Conclusion In order to reduce mortality, regular body check up especially with a chest X-ray is essential for the elderly to screen out early tuberculosis infection. References Taiwan Tuberculosis Control Report 2007. Centers for Disease Control, Department of Health, Republic of China (Taiwan). Taiwan Tuberculosis Control Report 2008. Centers for Disease Control, Department of Health, Republic of China (Taiwan). Taiwan Tuberculosis Control Report 2009. Centers for Disease Control, Department of Health, Republic of China (Taiwan).

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EVALUATION OF DIAGNOSIS AND TREATMENT OF PULMONARY TUBERCULOSIS SMEAR ACID FAST BACILLI NEGATIVE IN JAKARTA RESPIRATORY CENTRE (JRC) MOHAMAD YANUAR, ARIFIN NAWAS, AHMAD HUDOYO, JOEDO PRIHARTONO Persahabatan Hospital Division Pulmonology, Jakarta, Indonesia Introduction Tuberculosis is one of the most common infectious disease in developing countries. World Health Organization requires two positive acid fast bacilli or in case of a negative smear, a positif chest X-ray and symptoms suggestive of pulmonary tuberculosis infection. Pulmonary tuberculosis particularly from smear negative but 17% transmission disease from smear negative. Methods This a cohort study. We collected patients who were being treated as a smear negative pulmonary tuberculosis on the basis of clinical and radiologic ndings with antituberculosis agent for 6 months at JRC from January December 2009. We reviewed the medical records and evaluate on clinical response and radiography before and after treatment. Results A total 94 patients were collected the youngest was 17 years old and the oldest was 74 years old. The main symptoms was cough 92 patients (97.8%), breathlessness 34 patients (36.2%), fever 21 patients (22.3%), haemoptysis 20 patients (21.2%). We found 90 patient (95.7%) in radiologic nding was wide lesion and 4 patient (4.3%) was mild lesion. Clinical symptoms and radiologic ndings were decease after completely 6 month treatment. Conclusion Smear negative pulmonary tuberculosis diagnosis, includes the clinical signs and radiography should be made upon initiation of treatment, and at two point at the end of intensive phase and by the end of maintenance phase.

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STUDY TOTAL LYMPHOCYTE COUNT AS A PREDICT CD4+ OF CO-INFECTION TB-HIV PATIENTS IN PERSAHABATAN HOSPITAL NOVITA ANDAYANI, ELISNA SYAHRUDIN, ARIFIN NAWAS Persahabatan Hospital Division Pulmonology, Jakarta, Indonesia Introduction Co-Infection TB-HIV patient increase more progressive. To diagnosis and treatment early TB HIV need tool cheaper, easier but still signicant and appropriate like blood count. CD4 value used to evaluate treatment infection HIV and correlation with total lymphocyte count. This study want to know total lymphocyte count as predictor CD4 in coinfection TB HIV. Methods This study perform cross-sectional method patient with co-infection TB-HIV. Until now include 30 patient TB HIV and then analyzed total lymphocyte count as predictor CD4. We use correlation test and regression linier and to evaluate cut of point total lymphocyte count and CD4 in coinfection TB HIV. Results From 30 co-infection TB-HIV patients, there were men 87.7% (n = 26) and women (n = 4) and transmission HIV with IVDU 56.7% (n = 17), free sex 43.3% (n = 13), Tuberculosis symptom like cough 16.67% (n = 5), breathlessness, 63.3% (n = 19), hemoptysis 6.67% (n = 2), fatigue 6.67% (n = 2), loss of appetite 3.33% (n = 1), fever 3.33% (n = 1), positive acid fast bacilli sputum 53.3% (n = 16), negative acid fast bacilli sputum 46.7% (n = 14), there is correlation between total lymphocyte count and CD4+ (p = 0.04), there is no correlation between total lymphocyte count with wide and minimal lesion in chest X-Ray (p = 0.984), there is no correlation between total lymphocyte count with acid fast bacilli sputum positive and negative (p = 0.87). Conclusion There is correlation between TLC and CD4 in co-infection TB-HIV and TLC could substitute value of CD4 to evaluate and treatment coinfection TB-HIV, but no correlation between lesion in CXR with TLC and AFB sputum with TLC.

DEMOGRAPHIC, CLINICAL, AND RADIOGRAPHIC ASSESSMENT OF SYMPTOMATIC, SMEAR-NEGATIVE PULMONARY TUBERCULOSIS IN A PPMD SETTING IN ILOILO CITY RAYMOND LEE, MALBAR FERRER, ELLA MAE DIVINAGRACIA, ROSAURO CABANA, LORELEI SIRILAN, AMEE PONJE, ELCIE SOLIS, MART TAYO St. Pauls Hospital, Iloilo City, Philippines Introduction The burden of Tuberculosis control has long been a problem in our society. Much effort is being done to address the issue of case detection and treatment. Numerous cases of Pulmonary Tuberculosis are being referred to Public-Private Mix for DOTS (PPMD) annually, and in most instances, they are of sputum smear-negative type. Clinicians need to decide when to initiate empiric anti-Kochs treatment based only on symptoms and radiographic ndings, as a delay in the commencement of treatment could cause further transmission of the disease. Thus, an advocacy, heralded by a TB diagnostic committee, of treating smear-negative patients suspected of having active TB disease was started. As such, standard diagnostic parameters are warranted to ascertain the presence of active pulmonary TB in smear-negative cases and institute appropriate treatment regimen. Methods Retrospective descriptive study Setting: Public-Private Mix for DOTS (DOTS-SPH) in Iloilo City Patients: Total of 75 symptomatic, smearnegative TB patients enrolled in DOTS-SPH were included in the study. Results Majority (52%) of the patients included in the study were females, mostly young adults (32.0%) in their most productive years, residing in the urban areas (73.3%). Patients commonly presented with cough (84.0%), backpain (65.3%), weight loss of >10% (45.3%), easy fatigability (45.3%), and chest pain (44.0%). Most patients were under Category I (58.7%). The most common radiographic nding is the presence of an apical/upper lobe inltrates (68.0%). Conclusion Most patients presented with at least 3 or more constitutional symptoms, cough being the most common. The initiation of anti-Kochs medications relies mostly on chest radiographic ndings or bacterial culture. Standard Diagnostic and Treatment parameters are still warranted for validation. Strict guidelines on follow up such as repeat chest radiograph post-treatment should be implemented.

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THE DIRECT METHOD IN LIQUID MEDIA OF DRUG SUSCEPTIBILITY TEST OF MYCOBACTERIUM TUBERCULOSIS BY THE NITRATE REDUCTASE ASSAY MINJI SEO1, HYEJIN KIM1, HEEKYUNG YU1, YOUNG KIL PARK1, JAE-IL YOO2, GYUNG TAE CHUNG2, YEONG SEON LEE2, SUNGWEON RYOO1 1 Molecular Mycobacteriology Unit, Korean Institute of Tuberculosis, Seoul, Republic of Korea, and 2Centers for Infectious Diseases, National Institute of Health, Korea Centers for Disease Control and Prevention, Seoul, Republic of Korea Introduction Tuberculosis (TB) is still a major public health problem worldwide. Moreover, in developing countries, increase of drug-resistant TB and, also in that of multidrug-resistant (MDR) TB is have become a concern. However, MDR tuberculosis can be effectively treated if diagnosed properly. Thus, there is an urgent demand for new, rapid and moreover inexpensive accurate drug susceptibility testing (DST), particularly for low-income countries. In order to reduce the time and cost of DST, the nitrate reductase assay (NRA) method, depending on the ability of Mycobacteria tuberculosis to reduce nitrate to nitrite which can be detected by using specic reagents which produce a change in color, has been proposed as a rapid method for the detection of resistance to rifampicin (RIF) and isoniazid (INH) in low income area. So, in this study we performed direct NRA method in liquid media to reduce the turnaround time since the indirect method requires 26 weeks for isolation of the bacteria, the direct NRA method is more useful than the indirect method. Methods 10 directly sputum samples using a liquid medium containing growth supplements were tested by the nitrate reductase assay and the results of sensitivities and specicities for drugs were compared with the proportion method (PM) on LwensteinJensen medium. Results NRA results were available in 10 days for 10% of the specimen, in 11 days for 20% of the specimen, in 14 days for 40% of the specimen, and in 18 days 100% of the specimen. Also, the direct NRA method showed sensitivity and specicity for INH: 100% and 100%, RIF: 75% and 66.7% with AFB positive sputum samples. Conclusion Our results of NRA for the rapid detection of RIF and INH resistance in 10 to 18 days. We have highly sensitive and specic results for INH, but those were not good for RIF. This is because we have tested very few samples. Were testing more samples and correct NRA method before October, and then results will be better than now. This method is rapid and simple to perform and can reduce the time to report compared to classical conventional methods. NRA could be implemented in laboratories of limited resources countries.

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CLINICAL EVALUATION OF A LATERAL FLOW SEROLOGIC TEST IN THE RAPID DIAGNOSIS OF PULMONARY TB IN A PUBLIC-PRIVATE MIX FOR DOTS SETTING IN ILOILO CITY, PHILIPPINES DENNIS DUMAPLIN, MALBAR FERRER, ELLA MAE DIVINAGRACIA, ROSAURO CABANA, LORELEI SIRILAN, RODROSE GUZMAN-TRIVILEGIO, AMEE LOURDES PONJE, ELCIE SOLIS, MART TAYO St. Pauls Hospital, Iloilo City, Philippines Introduction Diagnosis of Pulmonary Tuberculosis (pTB) in a developing country with a limited resource relies largely on clinical signs and symptoms, sputum microscopy and chest radiography. In an endemic area such as the Philippines, the strict implementation of intensied case-nding and infection control measures which reduce the burden of TB, and thereby prevent spread of the disease at the earliest time, is crucial to saving lives. Culture methods, on the other hand, are not routinely used in the locality due to the low costeffectiveness and associated time constraints. By using serodiagnostic methods, the time required to reach a clinical decision to treat a suspected case of Pulmonary Tuberculosis may be drastically reduced. In this study we have investigated the clinical utility and diagnostic accuracy of a lateral ow serologic test in pTB diagnosis when used as an adjunct in the diagnosis and treatment algorithm in the PPM-DOTS setting in Iloilo City, Philippines. Methods An immuno-chromatographic TB STAT PAK II Assay was employed for the detection of antibodies to Mycobacterium tuberculosis in the human sera of TB suspects. Humoral response was analyzed in a group of 105 TB suspects (74 in the active pTB group of which 47 were smear-positive and 27 smear negative, and 31 in the non-active/control group of which 25 were having a disease other than TB and 6 were healthy subjects. Results The proportion of all test subjects with pTB who tested positive with the TB STAT PAK II Assay (sensitivity) was found to be 63.4%, while the proportion of all subjects without pTB who tested negative for the assay (specicity) was calculated to be 100%. The positive predictive value (PPV) and the negative predictive value (NPV) for the assay was 100% and 53.44%, respectively. Conclusion The serologic test performed with excellent specicity and acceptable sensitivity in pTB diagnosis in the endemic setting, though not enough evidence exists that they perform well enough to replace sputum microscopy. Being a pioneering study in the locality, it may prove helpful in providing local TB programs with critical preliminary information to guide appropriate use.

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CONSULTATIVE SURVEY ON PRIVATE PHYSICIANS PARTICIPATION IN THE PRIVATE-PUBLIC MIX DOTS SHEILLA CHECA, MALBAR FERRER St. Pauls Hospital, Iloilo City, Philippines Introduction Tuberculosis (TB) is still a major public health concern in the Philippines, ranking as the sixth (previously fth) leading cause of morbidity and mortality based on recent local data. The National Tuberculosis Program (NTP) reported 130,000 to 140,000 TB cases, mainly discovered and treated in government health units, of which 60% are highly infectious smear-positive cases. As of 2004, the case detection rate (CDR) improved from 53% in 2003 to 68% and the cure rate increased from 75% in 2003 to 80.6%. The involvement and participation of the private sector in the NTP implementation was started in 2003 and private-public mix DOTS (PPMD) facilities were established. The most important effect of PPMD is that it resulted in a marked improvement of the public sector performance in the PPMD site itself, from 53% to 68%. Methods Prospective, descriptive. Setting. Iloilo City. Subjects. Total of 93 physicians participated in DOTS referring physicians training seminar, 38 responded to the consultative survey questionnaire given. Results All respondents participated in DOTS referring physician training seminar. About 60.5% were given certicate as Certied DOTS referring physician. Thirty-two percent (32%) of the referring physicians refer patients to DOTS for almost 3 years. Seventy-one percent (71%) of the subjects claimed that there was no change in the number of patients since the physician started referring patients to DOTS clinics. Forty-ve percent (45%) of the patients were aware of the presence and services of DOTS clinics. Only 36% of patients agreed to go to DOTS clinics. Sixty-one percent (61%) of patients did not agree to go to the DOTS clinic. Only 40% of patients referred to DOTS clinics came back to clinic for follow up. About 78% of the referring physicians received advisory communications or updates about your referred patients by the DOTS clinics. Sixty-eight percent (68%) of the patients had complaints about their DOTS clinics treatment. More than two-thirds (68%) of the patients were satised of their DOTS clinic treatment. Seventy-one percent (71%) of the patients has no answer on the negative comments on DOTS clinic treatment. About half (50%) of the patients has no answer on the positive comments on the DOTS clinic treatment. Eighty-eight percent (88%) of the referring physicians did not receive any incentives from the PhilHealth. Conclusion All of the referring physicians participated on DOTS referring training seminar and 60.5% were given the certicate and 32% of them refers patients to DOTS for almost 3 years. Only 45% patients were aware of the DOTS clinic program and only 36% agreed to be treated under this program and only 40% of them had follow up with their referring physicians. Strengthening the awareness of the private physicians and the patients regarding the DOTS clinic program would inuence their decisions to be treated under this program.

DEMOGRAPHIC PROFILE OF TB PATIENTS TREATED AT UNIVERSITY OF PERPETUAL HELP DALTA-MEDICAL CENTER TB-DOTS CLINIC FOR THE PERIOD OF TWO YEARS (MAY 2007 TO APRIL 2009) NINO JESSIELITO DOYDORA, LEILA MAGSINO, EDZEL TAMAYO, IMELDA MANUEL Department of Internal Medicine, Section of Pulmonology, University of Perpetual Help DALTA Medical Center, Las Pinas, Philippines Introduction A descriptive, observational study to dene the demographic prole of patients diagnosed with tuberculosis at the UPHDMC-TBDOTS center for two (2) years. And to determine the effects of the different factors independently associated with the diagnosis of tuberculosis. Methods Included in the study are: all the patients who were diagnosed with tuberculosis from May 2007 to April 2009. Patients were interviewed and asked specic questions to obtain the data needed. Patients prole were grouped according to Age, Gender, Civil Status, Occupation, Smoking History, Alcoholic Drinking History, and Presence of Comorbidity. Results Of the 212 patients treated, 178 patients (83.9%) are between 2165 years old, male patients comprise 67.9% (144), and most of them (131) are married (61.8%). Almost half of the patients are unemployed (47.2%). Among the group, smokers (52.8%) slightly outnumbered the nonsmokers (47.2%). This is similar with regards to the alcoholic drinking history of the patients. The alcoholic drinkers at (110) or 51.9% over the non-alcoholic drinkers, at (102) or 48.1%. However, the number of patients who had no comorbidities (136) were almost twice the number of those patients with comorbidities (76), or 64.2% over 35.8%, respectively. Conclusion The study showed that among 212 TB patients, more than half of them belong to the economically productive sector, and male sex being more dominant, conrming the ndings of several similar local studies. The study also showed that among the patients who drink alcohol and those with comorbidity, are most likely categorized in PTB I. And those patients in the younger age group, who smoke and drink alcohol are more likely to have positive AFB microscopy results.

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PROGRAMMATIC MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS DURING PREGNANCY: CLINICAL COURSE, SAFETY & OUTCOME RHODA BABALO, ROQUE GONONG, LAWRENCE RAYMOND, MARVE DUKA, GERMELYN DE MESA Lung Center of the Philippines, Quezon Avenue, Quezon City, Philippines Introduction Therapeutic abortions were once recommended for women with tuberculosis, as pregnancy was thought to be deleterious to the disease course. This case series illustrates the unique challenges presented by pregnancy and Multi-Drug Resistant Tuberculosis. Thus, a Programmatic Management for Drug Resistant Tuberculosis (PMDT) is vital for the treatment of Multi-Drug Resistant Tuberculosis and prevention of its development especially in patients who have demonstrated prior non compliance. Methods Maternal treatment records were reviewed from January 2004 to October 2007 at Programmatic Management of Drug Resistant Tuberculosis (PMDT) at the 3 Treatment Centers diagnosed with Multi-Drug Resistant Tuberculosis. Analysis of Age, radiographic ndings, constitutional symptoms, gestational age, and adverse reactions to individualized treatment regimens were done. Results Patients were mostly in their second or third decade of life and during their rst trimester of pregnancy. All patients exhibited cough (100%) as the primary symptom followed by chest pain (75%) and dyspnea (58.3%). Majority of patients have bilateral inltrates (66.6%) and cavitation (50%) on their baseline chest radiograph. Isolation of Mycobacterium tuberculosis both from smear and culture with 6979% resistance to at least 34 rst line drugs were seen in all cases. Majority of the patients were in the Intensive Phase of treatment (66.6%) during the rst trimester of pregnancy which is why the injectable agent as well as several second line drugs were discontinued due to proven fetal toxicity. All babies were delivered term except for 1 patient born prematurely and exhibited sepsis neonatorum. There were 4 reported cases of babies born small for gestational age. The treatment outcome for this cohort showed a success rate of 92% with one patient who defaulted (8%). Conclusion These case series proved that gestational Multi-Drug Resistant Tuberculosis patients has a success rate under a Programmatic Management for Multi-Drug Resistant Tuberculosis (PMDT). Therefore, adherence to the treatment regimen is a must not just to provide cure but also to prevent disease progression and transmission to the newborn.

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SURVEILLANCE EVALUATION OF THE INTEGRATED DISEASE SURVEILLANCE PROJECT (IDSP) WITH RESPECT TO TUBERCULOSIS IN SHIMLA DISTRICT OF HIMACHAL PRADESH, INDIA OMESH KUMAR, VIDYA RAMACHANDRAN Directorate of Health Safety and Regulation, SHIMLA, Himachal Pradesh, India Abstract withdrawn prior to print.

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DEVELOPMENT OF MDRTB AMONG PATIENTS TREATED WITH CATEGORY II REGIMEN: A LUNG CENTER OF THE PHILIPPINES EXPERIENCE AUGUSTO SABLAN JR, JOVEN GONONG, LAWRENCE RAYMOND, VIVIAN LOFRANCO Lung Center of the Philippines, Quezon Avenue, Quezon City, Philippines Introduction The use of category II regimen is oftentimes questioned because it is contradictory and would represent one of the main errors which should be avoided in a retreatment regimen and that is adding one drug to a failing regimen. In a retrospective study done in India by Shah et al regarding drug-resistance pattern in previously treated patients, they studied 482 previously treated pulmonary tuberculosis patients and reported that resistance to INH and INH plus RIF was 12.86 and 15.77%, respectively. In an original article published in the Indian Journal of Tuberculosis in 2008 by Mehra et al, they analyzed the treatment outcome of Category I smear positive relapse and failure cases treated with category II. The study was an 11-year follow-up of cases. They concluded that failure cases of category I treated with category II were observed to have a signicantly lower success rate with a p value of <0.05 as compared to relapse cases. They further suggested the need for reappraisal of category II re-treatment regimen for failure and relapse cases. Methods Retrospective Cohort study. Results The Z-test for two proportions was used with a condence level of 95%. With a Z value of 1.563, there was no signicant difference between patients with Category I failure and Relapse as indications for Category II treatment who developed MDR-TB. With a Z value of 0.792, there was also no signicant difference between patients with Relapse and RAD. However, with a Z value of 2.271, there was a signicant difference between patients with Category I failure and RAD as indications for Category II treatment who developed MDR-TB. Conclusion The frequency of MDR-TB among patients who received category II treatment from December 2006 until December 2009 at the Lung Center of the Philippines was 35.5%. The highest was among Category I failure at 45%, Relapse 33.3% and RAD at 27.5%. There was a signicantly higher proportion of patients who developed MDR-TB among patients with category I failure as compared to RAD. We recommend that for patients with Category I treatment failure, Relapse and RAD be started on standardized treatment regimens for MDR-TB while awaiting results of culture and sensitivity.

EFFICACY AND SAFETY OF AMURUBICIN (AMR) FOR THE ELDERLY WITH REFRACTORY RELAPSE SMALL CELL LUNG CANCER (SCLC) WHO HAD PREVIOUS TREATMENT NOBUHIRO ASAI, YOSHIHIRO OHKUNI, AKINA KOMATSU, RYO MATSUNUMA, KEI NAKASHIMA, KATSUTOSHI ANDO, DAISAKU YASUI, MASAFUMI MISAWA, NORIHIRO KANEKO Respiratory Medicine, Kameda General Hospital, 929 Higashi-cho, Kamogawa City, Chiba, Japan Introduction Lung cancer is the leading cause of cancer death in Japan and 1520% of which is SCLC. More than 50% of patients newly diagnosed as SCLC are older than 70 years. We retrospectively analyzed 32 elderly patients with SCLC refractory to previous chemotherapy who received AMR monotherapy with the aim of evaluating the efcacy and safety of the drug. Methods Thirty two patients (male 30/female 2) consisting mainly of stage III, IV, PS of 02 had histologic or cytologic conrmation of SCLC. They were classied into 3 groups; 24 extensive disease (ED), 7 limited disease, and 1 postoperated. They received intravenous AMR at dose of 2540 mg/m2 on three consecutive days every 3 weeks. The dose of AMR was modulated according to medical conditions. Results The response rate (RR) and the disease control rate (DCR) of refractory relapse cases were 42.3% and 61.5% respectively. The median of overall survival time was 15.1 months, the median time to progression was 2.9 months. One-year and 2-year-survival rate were 76.1% and 28.3% respectively. The most frequent toxicity was myelosuppression: grade 34 leukopenia, neutropenia, and thrombopenia were seen in 38%, 47%, and 2.9% respectively, while febrile neutropenia was 5.9%. No severe non-hematological toxicity was seen, except one grade 3 vomiting. There was no signicant difference in the frequency of the grade 35 hematologic or non-hematologic toxicity between the elderly (70 years) and non-elderly (<70 years) patients. Conclusion AMR has efcacy and safety in the elderly with refractory relapsing SCLC with acceptable toxicity depending on the medical condition.

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OUTCOMES OF DIAGNOSED PTB PATIENTS REFERRED TO FIFTY NINE (59) DIFFERENT HEALTH UNITS IN QUEZON CITY A SIX (6) MONTHS RETROSPECTIVE STUDY JANETTE MATA, DAPHNE BATE Lung Center of the Philippines, Quezon Avenue, Quezon City, Philippines Introduction The main goals of tuberculosis treatment are to cure the individual with the disease and minimize the transmission of Mycobacterium tuberculosis to others in the community. To improve adherence and cure rates, directly observed therapy is recommended for the treatment of pulmonary tuberculosis. Methods All patients diagnosed with PTB at Lung Center of the Philippines, OPD Department/PHDU referred to different local health units from January 1, 2008 to June 30, 2008, were included in the study. All of these patients were followed up at their respective Local Health Units and treatment outcomes were calculated to determine the success rate. Results Of 100 patients included in the study, 49% were declared cured and 48% were declared treatment completed. There were also 2 mortalities and the outcome of 1 transferred patient to other facility was not known. Conclusion Success rate was 97% which was above the ideal rate of 85% compared to the study done abroad and complete attendance of the patients to their respected health center where they were referred to manifest the willingness of each patients to free themselves from their illness.

A CASE OF INFECTIOUS HUGE BULLA CAUSED BY LUNG CANCER NOBUHIRO ASAI, YOSHIHIRO OHKUNI, TAKUYA IWASAKI, RYO MATSUNUMA, KEI NAKASHIMA, KATSUTOSHI ANDO, AKINA KOMATSU, MASAFUMI MISAWA, NORIHIRO KANEKO Respiratory Medicine, Kameda General Hospital, 929 Higashi-cho, Kamogawa City, Chiba, Japan Introduction A 78 year-old man visited ER complaining of continuous fever, chest pain and general fatigue. Chest X-ray showed a giant infectious bulla with the size of 30 cm on the left lung. (This is the largest, as far as we could conrm by Pubmed.) He had never been pointed out any abnormality on X-ray before; he actually had no abnormal ndings on the latest medical check-up last year. Methods Diagnostic procedure including bronchoscopy revealed lung cancer (large cell carcinoma) in his left lung major airway. Results The malignant tumor closed the airway resulting in the formation of a giant bulla. A giant bulla has been sporadically reported, however, the origin has never been known before. We suggest that an obstruction, caused by lung cancer for instance, may cause air trapping, resulting in the bulla formation. Conclusion In case of huge bulla which rapidly increases in size, lung cancer should be one of the differential diagnosis and be investigated.

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LUNG CANCER CHARACTERISTICS WITH LOW DOSE CHEST CT SCREENING IN KOREA: COMPARISON WITH KOREAN GENERAL POPULATION SEUNG HO CHOI, CHANG HYUN LEE, SEONG YEON KWON Seoul National University Hospital, Gangnam Center, Yeoksam Dong, Gangnam Gu, Seoul, South Korea Introduction Lung cancer screening with low dose chest CT is becoming popular in health checkup in Korea. But, its clinical usefulness is not well known yet. So we try to nd characteristics of lung cancer patients who were diagnosed in health checkup compared to general population. Methods A total of 15,615 asymptomatic Korean adults who received low dose chest CT (LDCT) for lung cancer screening in Healthcare system Gangnam Center health checkup program from October 2003 to June 2007. We analyzed clinical and pathologic characteristics of lung cancer patients diagnosed by screening low dose chest CT in health checkup. Results Thirty-ve lung cancers occurred. Lung cancer detection rates were 0.22% (crude annual incidence rate (61.0/100,000/year). Male and female ratio was 6:4. 18 of 35 cancers occurred in high-risk group (>20 pack-year smoking) and 17 in low risk group (ex-smokers and non-smokers). 76% of lung cancers were less than 3 cm (<1 cm 30%, <2 cm 22%, <3 cm 24%). Percentage of pathologic stage of those patients were 45.7% (IA), 11.4% (IB), 8.5% (IIB), 11.4% (IIIA), 8.5% (IIIB). Of 35 patients with lung cancer, VATS segmentectomy or lobectomy was performed in 10 patients and lobectomy in 16. Four patients underwent chemotherapy and 5 patients was managed with supportive therapy because of advanced stage or old age. Two patients died despite of treatment and other patients survived. LDCT screening in health checkup detected lung cancers showed higher rate in annual incidence (also in low risk group: non-smokers and female) and in early, operable stage than Korean general population. Adenocarcinoma (especially BAC) is more prevalent. Some patients with BAC histology in early stage could be treated with VATS. Conclusion Lung cancers detected in screening have somewhat different clinical characteristics from general population and LDCT may be useful for discovering lung cancer in early, operable stage.

PULMONARY BLASTOMA: A CASE REPORT OF A VERY RARE PULMONARY TUMOR ISSER SUGAY, IVAN VILLESPIN Center for Respiratory Medicine, University of Santo Tomas Hospital, Manila, Philippines Introduction Pulmonary Blastoma is a rare tumor accounting to 0.250.5% of all malignant lung neoplasms. It is a very aggressive tumor and is associated with a very poor prognosis. While surgery is the preferred treatment and chemotherapy may be helpful, the role radiotherapy for this large lung tumor is still unclear. In the Philippines, there has been only one reported case of pulmonary blastoma. We present a case report of a 44-year old female with a massive lung tumor, later diagnosed with pulmonary blastoma based on the histopathology. Methods A 44-year old female had a 2-month history of dyspnea, cough and weight loss whereby radiographic examination showed a right lung mass. CT scan guided biopsy of the right lung mass was initially contemplated however patient cannot lie supine and as a result open lung biopsy of the mass was done under general anesthesia. Results The right lung mass measured 16 cm 12 cm 10 cm. Histopathology of the lung mass initially revealed round cell cancer versus lymphoma versus liposarcoma. Immunostaining results showed positive for vimentin, S100, cytokeratin and desmin and it was signed out as pulmonary blastoma. A multidisciplinary meeting was made and initial plan was to do radiotherapy followed by total excision of the mass and adjuvant chemotherapy, however patient decided to be sent home. The patient expired two days after discharge. Conclusion As of year 2002 there have only been around 200 cases of pulmonary blastoma that have been reported. Owing to the rarity of this lung malignancy, little is known about its mechanism as well as its treatment. It was termed blastoma to reect that the tumors arise from the pulmonary blastoma in a similar manner to other tumors developing from fetal tissue. This report intended to increase the awareness of clinicians regarding the presence of this very aggressive tumor.

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TWO COMMONLY USED PREDICTION MODELS (MAYO AND VA) TO ESTIMATE THE PROBABILITY OF MALIGNANCY IN PATIENTS WITH SOLITARY PULMONARY NODULES ARE NOT APPLICABLE IN A COUNTRY WITH HIGH INCIDENCE OF TUBERCULOSIS SHANE V CENIZA1, ALBERT L RAFANAN2, MARIA THERESA A CANETE3 1 Section of Pulmonary Medicine, University of the Philippines Philippine General Hospital, Manila, Philippines, 2Department of Internal Medicine, Chong Hua Hospital, Cebu City, Philippines, and 3Statistician and Epidemiologist, Chong Hua Hospital, Cebu City, Philippines Introduction The Philippines ranks ninth on the list of 22 high-burden tuberculosis countries (WHO Global TB Report 2009); and a larger proportion of solitary pulmonary nodules (SPN) are due to tuberculosis. We determined if two prediction models (Mayo and VA) can be used to estimate the probability of malignancy of SPN in the Philippines. Methods All chest roentgenograms with SPN from October 2006 to March 2008 were reviewed by two independent radiologists. Data on variables used in the VA and Mayo Clinic models were collected. Each patients nal diagnosis was compared with the probability of malignancy predicted by the two models (VA and Mayo Clinic). ROCs and accuracy of each model were calculated. Results Of a total of 17,881 chest radiographs, 81 had SPN. Five were excluded for lack of a denitive diagnosis. Of the remaining 76, thirty-nine (51%) were males. The mean age (SD) was 55 17 years old. Nineteen (25%) presented with hemoptysis; and 33 (43%) were current smokers with a mean (SD), of 10 (15) pack years. The mean nodule size was 2.4 (1.5) cm. Twenty-one (25%) had a speculated nodule margin while 11 (14%) had calcications, with 8 being speckled and eccentric. Seven percent (n = 5) had history of extrathoracic malignancies. Malignancy was the pathologic diagnosis in 25 (32.9%). Both models predicted all 76 (100%) as malignant, thus no ROC curves could be obtained. Conclusion The prediction models by both the VA and Mayo give a poor estimate to the probability of malignancy of SPN in the Philippines.

CUTANEOUS SIDE EFFECTS OF EPIDERMAL GROWTH FACTOR RECEPTOR-TYROSINE KINASE INHIBITOR IN THE TREATMENT OF LUNG CANCER: DESCRIPTION AND ITS MANAGEMENT CHOO KHOON ONG, WOOI CHIANG TAN, LEE CHIN CHAN, IRFHAN ALI, ABDUL RAZAK MUTTALIF Respiratory Medicine, Penang General Hospital, 124E, Jalan Teratai, Taman Jaya, 14000 Bukit Mertajam, Penang, Malaysia Introduction Epidermal growth factor receptor (EGFR)-Tyrosine Kinase inhibitors (TKI) like erlotinib and getinib have been approved as monotherapy for the treatment of patients with locally advanced or metastatic non small cell lung cancer (NSCLC) after failure of at least one prior chemotherapy regimen. The use of EGFR-TKI is associated with unique and dramatic dermatologic side effects. Methods We report 2 patients with NSCLC developing a typical acneiform eruption shortly after initiation of EGFR-TKI. Results The rst case is a 60 year old Chinese lady who was diagnosed to have right lung cancer. She had right lower lobectomy done in 2002. In 2006, she had disease recurrence and bone metastases to the right hip and sacral bone; of which she was given radiotherapy followed by chemotherapy. Oral erlotinib was started when her disease progressed despite on chemotherapy. She developed acneiform eruption over the face and upper trunk 10 days after commencement of erlotinib followed by alopecia, paronychia, seborrhoeic dermatitis and xerosis. The rash improved with oral doxycycline and topical treatment of fucidin and benzoyl peroxide. Repeated computer tomography (CT) scan at one month showed almost 50% reduction of the size of the pulmonary nodules. Our second case is a 43 year old Malay man with right lung cancer stage IIIB, who has failed rst and second line chemotherapy. He was given radiotherapy followed by oral getinib. He was noted to have acneiform lesion over upper trunk and face after 2 weeks of getinib treatment. The rash improved with topical benzoyl peroxide and oral doxycycline. CT scan done at one month later showed improvement of the tumor size. Conclusion Although these new targeted therapies have low systemic toxicity, cutaneous side effects are common and can be troublesome. Proper pre-treatment counseling and management will improve the treatment compliance and avoid unnecessary interruption of the TKI use. TKI induced skin rash appears to be a visible marker of anti-tumor activity and therapeutic efcacy. Literature reviews on management of TKI induced drug rash will be discussed.

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PHASE I STUDY OF CARBOPLATIN AND AMURUBICIN WITH A BIWEEKLY SCHEDULE IN PATIENTS WITH ADVANCED NON-SMALL CELL LUNG CANCER MASAO ICHIKI, MASAYUKI NAKAMURA, TAKAAKI TOKITO, TOMOMI SEKIZUKA, MASAKI OKAMOTO, HISAMICHI AIZAWA Respiratory Medicine, Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, Japan Introduction A phase I study was conducted to determine the maximum tolerated dose (MTD) and dose limiting toxicity (DLT) of carboplatin in combination with amurubicin using a biweekly schedule in patients with advanced non-small cell lung cancer (NSCLC). Methods The criteria for eligibility as subjects of the study included the patients with NSCLC (stage IIIb or IV) histologically or cytologically conrmed, patients with no prior treatment, or measurable disease. Amurubicin (on day 1 and 2) was given in combination with a xed dose of carboplatin (on day 1) at an area under the concentration time curve (AUC) of 3, every 2 weeks. The starting dose of amurubicin was 30 mg/m2, and the dose was increased in increments of 5 mg/m2. Three to six patients were allocated to each dose level. Results A total of 10 patients (6 male and 4 female) with a median age of 68 years (range 5473) and a median ECOG performance status of 0 (range 01) were enrolled. The MTD of amurubicin proved to be 40 mg/m2, and the DLT was neutropenia, which was improved well when the patients were treated with G-CSF. Gastrointestinal toxicity was well-tolerated. Four out of 10 patients (40%; 95% condence interval (CI): 12.073.8%), who received 4 cycles or more responded to this combination therapy. The recommended dose for the phase II study is amurubicin 35 mg/m2 with the carboplatin at AUC of 3. Conclusion This biweekly regimen is highly effective and acceptable, and thus, the present data suggest that the regimen be suitable for outpatients.

CLINICAL OUTCOMES AND PROGNOSTIC FACTORS IN ELDERLY PATIENTS WITH STAGE IIIB/IV NON-SMALL CELL LUNG CANCER YON JU RYU, JI HYE KIM, JIN HWA LEE, EUN-MI CHUN, JUNG HYUN CHANG, SUNG SHINE SHIM Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University, School of Medicine, Mokdong Hospital, Mok 5-dong, Yangcheon-gu, Seoul, South Korea Introduction The average age of patients with lung cancer is increasing and more than half of advanced non-small cell lung cancer (NSCLC) occurs in elderly with a median age at diagnosis of 70 years. The aim of our study was to examine the clinical outcomes and prognostic factors contributing to mortality in elderly patients with advanced NSCLC. Methods 85 patients aged 70 years and over receiving a histopathological diagnosis of locally advanced (14 with stage IIIB disease) NSCLC and metastatic NSCLC (71 with stage IV disease) were collected between 2005 and 2009, and reviewed retrospectively. Results The median age of the patients was 75 years (range, 7090), and 61 patients (72%) were male. 39 patients (46%) were never-smokers and 11 patients (13%) were in a malnourished state, with body mass index <18.5 kg/ m2. Histological types were as follows: squamous, 34%; adenocarcinoma, 33%; non-small cell type, 25%; large cell carcinoma, 2%; and others, 6%. The initial treatments included chemotherapy (52%) and radiotherapy (7%), but 44% of the patients received supportive care only. Overall mortality was 78% (66/85), with a median survival of 6 months (range, 142) after diagnosis. One-year survival was 39.9% and three-year survival was 9.0%. Cancer progression was noted as a primary cause of death in 59 patients (69%). The 7 patients who died of other causes, such as a infection (n = 4), ischemic heart disease (n = 2), and cerebrovascular accident (n = 1) were excluded from the survival analysis. Regardless of age, nutritional status, stage IV disease, initial treatment or lung function, male gender (hazard ratio (HR), 9.6; 95% condence interval (CI), 2.833.6; p < 0.0001) and smoking history (HR, 4.4; 95% CI, 1.512.5; p = 0.006) were independent predictors of shorter survival based on a Cox proportional hazards model. Conclusion A substantial portion of elderly patients with advanced NSCLC did not receive standard treatment. Never-smokers and women were better survival factors in elderly patients with advanced NSCLC.

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EGFR TYROSINE KINASE INHIBITOR AS FIRST LINE TREATMENT IN METASTATIC LUNG ADENOCARCINOMA ANNA FEBRIANI, LAKSMI WULANDARI, SLAMET HARIADI, YUSUF WIBISONO Department of Pulmonology, Dr. Soetomo General Hospital, Faculty of Medicine, Jl. Ketintang Wiyata 02/25, Surabaya, Indonesia Introduction In Dr Soetomo General Hospital Non-Small-Cell Lung Cancer (NSCLC) accounts for approximately 80% of all lung cancers, 40% of which present with distant metastases including to the brain. Getinib is one of novel targeted therapy that inhibits the tyrosine kinase activity of the epidermal growth factor receptor (EGFR-TKI) by competitively blocking the ATP binding site. Getinib has shown a clinical efcacy in patients with advanced NSCLC who have received or progressed after prior chemotherapy regimens, but can be used also as rst line treatment. We reported a patient with metastatic NSCLC to the brain which receive Getinib as rst line treatment. Results A 45 year old man presented with double vision since 3 weeks before admission. Brain CT showed a hyperdense area in the subcortical segment of the left parietal lobe which suggests a metastatic lesion. In search of the primary tumor we performed chest X-ray and found a right lung tumor with milliary nodule in both lung eld. CT-Scan of the thorax showed right lung tumor with consolidation and bone destruction in the thoracal vertebrae. The biopsy revealed a lung adenocarcinoma. Patient got getinib as rst line treatment for almost 10 months with partial response as the overall result. There were improvements in clinical manifestation, radiologic nding, and the quality of life. The adverse effect of the drug was generally tolerable. Conclusion In metastatic NSCLC patient, getinib successfully used as rst line treatment and should be considered as one of alternative treatment option in advanced stage NSCLC, particularly in adenocarcinoma.

GEFITINIB-RELATED INTERSTITIAL LUNG DISEASE IN TAIWANESE PATIENTS WITH NON-SMALL CELL LUNG CANCER SHIH-CHIEH CHANG, CHENG-YU CHANG, CHONG-JEN YU Thoracic Division, Internal Medicine, National Yang-Ming University Hospital, Taiwan Introduction Getinib (Iressa, AstreZeneca, Wilmington, DE) is effective in the treatment of non-small cell lung cancer (NSCLC), especially in the Asian population. However, interstitial lung disease (ILD) is usually a serious pulmonary adverse effect and almost leads to cessation of getinib treatment. In this study, we investigated the incidence, clinical features and prognosis of getinib-related ILD in Taiwanese patients with NSCLC. Methods This was a retrospective observational study conducted in two medical centers and a local teaching hospital. Results A total of 1080 patients with NSCLC, who received at least one dose (250 mg/day) of getinib treatment, were enrolled. Of these, 42 patients were diagnosed with ILD. Twenty-four of the 42 patients were diagnosed with getinib-related ILD (Incidence 2.2%). The main manifestations of ILD included dyspnea, cough and hypoxemia. Seven (29.1%) of the 19 patients had concomitant elevation of liver function tests at time of presentation with getinibrelated ILD. Eight (33.3%) of the 24 patients with getinib-related ILD required invasive mechanical ventilation and all patients were treated with steroids. Twenty-one patients (87.5%) discontinued getinib treatment without further rechallenge. Ten (41.6%) patients died directly from ILD and in-hospital mortality was 55%. Eleven patients received subsequent cytotoxic chemotherapy with a mean of 33.5 days after ILD events. Cox regression analysis demonstrated that getinib non-responder was the only signicant predictor of in-hospital mortality. Conclusion Taiwanese patients with NSCLC had a relatively high incidence of ILD during getinib treatment. Getinib-related ILD is usually lifethreatening, especially in getinib non-responders.

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PRX1 PROVIDES RESISTANCE TO DOCETAXEL-INDUCED APOPTOSIS IN LUNG CANCER CELLS HAK-RYUL KIM, KI-EUN HWANG, SO-YOUNG KIM, EUN-TAIK JEONG Internal Medicine, Wonkwang University School of Medicine, 344-2 Shinyong-dong Iksan, Jeonbuk, South Korea Introduction Prx1 is a major 2-Cys peroxiredoxin family member and is frequently elevated in several human cancers including lung, oral, prostate, and breast cancers, and this seems to confer increased treatment resistance. Although Prx1 suppresses radiation-induced c-Jun NH2-terminal kinase (JNK) activation and apoptosis in non-small cell lung cancer (NSCLC), the precise mechanism of chemoresistance is not clearly known. In this study, we investigated the role of Prx1 in docetaxel-induced apoptosis of A549 lung cancer cells. Methods We generated shRNA targeting Prx1 in A549 cells to test the sensitivity to docetaxel treatment. Cell viability was measured by MTT assay. The change of expression of Prx1, PARP, Akt, and FoxO1a after docetaxel treatment was examined by Western blotting. A549 scramble and knock-down cells were pretreated with or without LY294002, and then treated with docetaxel, and cell lysate was used to carry out Western blotting. Results We found that Prx1 knock-down increased apoptotic potential through activation of caspase cascade. In addition, inhibition of Prx1 by shRNA suppressed the phosphorylation of Akt and FoxO1a, a substrate of Akt, by docetaxel treatment in A549 cells. Furthermore, PI3K inhibitor LY294002 inhibited the phosphorylation of FoxO1a and increased the cytotoxicity of docetaxel in A549 cells. Conclusion These ndings suggest that Prx1 may modulate the chemosensitivity of lung cancer A549 cells to docetaxel through suppressing FoxO1ainduced apoptosis.

MEDIASTINAL YOLK SAC TUMOR IKA TRISNAWATI1, EKO BUDIONO1, SUMARDI1, BAMBANG SIGIT RIYANTO1, AGUS FITRIYANTO ACHMAD2 1 Division of Pulmonology, and 2Resident, Department of Internal Medicine Faculty of Medicine Gadjah Mada University/Dr. Sardjito Hospital, Yogyakarta, Indonesia Introduction Yolk sac tumor is a germ cell tumor of nonseminomal type. Its incidence is extremely rare: 2.7 in 106 people/year.1 A pure yolk sac tumor is rarely found in adults, while that of mixed type is more often.2 Yolk sac is a primary tumor of gonad. Other locations rarely affected are sacrococygeal area, mediastinum, vagina, bladder, liver, nasopharynx, posterior fossa cranialis and face.3 Results A 19 years old male patient, was presented with major complaint of chronic cough. Other symptoms were dyspnoea and loss of weight. A chest x-ray picture conrmed by a CT Scan conrmed an anterior mediastinal mass. A right side pleural effusion with metastatic nodule presents in the posterior lobe. A ne needle aspiration of the mass resulted a malignant thymoma. Patient developed symptoms of parestesia and weakness in his lower extremity and difculty in urination. An MRI examination showing compression fracture of the thoracal vertebrae VIII and local hypointensity of medulla spinalis indicated a metastasis. He received chemotherapy, and A CT scan evaluation carried after 4th cycle showed a soft tissue mass smaller than the previous one. Pathology examination following mass debulking showed atypical and polymorphic tumor cells with round and oval nucleus, hyperchromatic, distinct nucleolus, high level of mitosis, conrmed a diagnosis of Yolk sac tumor. Level of AFP > 200,000 ng/mL and total beta HCG < 2 mIU/mL supported this diagnosis. The patient deceased 6 months after admission due to respiratory failure. Conclusion Despite its rare occurrence, the differential diagnosis of yolk sac tumor has to be included in a mediastinal mass cases. References 1. Birch JM, Marsden HB, Jones PH, Pearson D, Blair V. Improvements in survival from childhood cancer: results of a population based survey over 30 years. Br Med J 1988; 296: 13726. 2. Krag Jacobsen G, Barlebo H, Olsen J, Schultz HP, Starklint H, et al. Testicular germ cell tumours in Denmark 1976-1980. Pathology of 1058 consecutive cases. Acta Radiol Oncol. 1984; 23: 23947. 3. Shebib S, Sabbah RS, Sackey K, Akhtar M, Aur RJ. Endodermal sinus (yolk sac) tumor in infants and children. A clinical and pathologic study: an 11 year review. Am J Pediatr Hematol Oncol. 1989 (Spring); 11: 369.

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ANALYSIS OF THE EGFR MUTATIONS IN NON-SMALL CELL LUNG CANCER PATIENTS AFTER EGFR-TKIS TREATMENT MIDORI MATSUO, TOMONAGA NANAE, IZUMIKAWA KOICHI, YAMAGUCHI HIROYUKI, IKEDA TAKAYA, NAKATOMI KATSUMI, NAKAMURA YOICHI, TSUKAMOTO KAZUHIRO, KOHNO SHIGERU Department of Internal Medicine, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki City, Japan Introduction Background: Getinib and Erlotinib are the epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) that have the dramatically effects in selective patients with non-small cell lung cancer (NSCLC). EGFR mutations predict response and survival in patients treated with EGFRTKIs. However, most patients have a relapse within 1 year after the initiation of therapy. Several mechanisms of resistance to EGFR-TKIs have also been reported, such as MET amplication, L861Q and hepatocyte growth factor (HGF). The most important mechanism is a secondary EGFR mutation, threonine to methionine at codon 790 in exon 20 (T790M). Therefore, we analyzed EGFR mutations after EGFR-TKIs treatment in addition to before treatment. Methods Materials and methods: 99 patients were analyzed EGFR mutation status between July 2004 to December 2009 in our institution. 71 patients were treated with EGFR-TKIs (Getinib 67 cases, Erlotinib 9 cases), and EGFR mutations were detected in 31 patients. When tumor was relapsed, we got written informed consent, and re-examination of EGFR mutations was performed. EGFR mutations were examined by mutant-enriched polymerase chain reaction method and/or peptide nucleic acid-locked nucleic acid (PNALNA) PCR clamp method. Samples were biopsied tissues, surgically resected tissues, bronchial washing liquids, and pleural effusion, and we used relapsed tumor samples at secondary analysis. In addition, we evaluated the response to treatment and progression free survival. Results 31 patients harboring EGFR mutations treated with EGFR-TKIs. Response rate was 74.2% (23/31). Within 1 year, most patients were relapse (83.9%, median 149 days). In 10 patients, we could analyze EGFR mutations after treatment. T790M was detected in 4 patients. Despite emergence of T790M, readministration of getinib and treatment of erlotinib after getinib was effective in one patient. Conclusion These results suggested the importance of EGFR analysis after relapse in patients treated with EGFR-TKIs. We must consider why erlotinib was effective in patients with T790M, and screen appropriate subjects of readministration of EGFR-TKIs. The new therapeutic strategy according to the mechanism of resistance to EGFR-TKI is expected.

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CASE REPORT: RIGHT LUNG SQUAMOUS CELL CARCINOMA WITH MASSIVE HEMOPTYSIS MARTINUS GINTING, BOEDI SWIDARMOKO Persahabatan Hospital, University of Indonesia, Division Pulmonology, Indonesia Introduction Hemoptysis is the presenting symptom in 7 to 10% of patients with lung cancer. Approximately 20% will have hemoptysis some time during their clinical course. However, massive hemoptysis is a rare event, with 3% having terminal massive hemoptysis. Methods Most patients experience blood-streaked sputum. Santiago et al., reviewed the records of 264 patients who underwent bronchoscopy for unexplained hemoptysis in order to determine its causes. Hemoptysis results from necrosis and destruction of lung parenchymal support for vessels, as well as from tumor neovascularization. Radiation therapy (endobronchial or external beam) and laser therapy may be useful in controlling bleeding lung tumors. Massive hemoptysis due to lung cancer has a much poorer prognosis than hemoptysis of other etiologies. Results Reporting a 46 years-old male who underwent radiotherapy to stop massive hemoptysis. Patient came to hospital complaining worsening hemoptysis. Volume of hemoptysis expectorated was 200 cc and during hospitalization the hemoptysis still occurred with average volume of 250 cc per day. The hemoglobin level decreased from 9.9 to 8.7 g/dl with ongoing hemoptysis, hence the patient was diagnosed with massive hemoptysis in the Persahabatan Hospital. There was a lymph node enlargement in the neck. The patient underwent a bronchoscopy and found there was an inltrative stenosis in both left and right main bronchus and block almost all lumen obstructing the bronchoscope from entering the lumen. Forceps biopsy was performed and the pathology result was squamous cell carcinoma. Patients was diagnosed with right lung squamous cell carcinoma T4N0M1b (neck lymph node). The patient then underwent low dose radiotherapy (1.8 gy) to stop the hemoptysis and dexamethasone was given as a premedication. The hemoptysis stopped on the 5th of radiotherapy. The radiotherapy was planned for 25 times and after that chemotherapy will be performed. Conclusion In this patient radiotherapy was performed in order to stop the hemoptysis, and the hemoptysis stop on the 5th of radiotherapy. Bronchoscopy was performed to identify the source of bleeding and for diagnostic of the tumor. The low dose radiotherapy (1.8 gy) was performed to minimize edema caused by the radiation and dexamethasone as premedication was also given to prevent edema. Chemotherapy will be performed after completion of radiotherapy.

Conclusion Schwannomas are arising from sheaths of spinal nerve roots and thoracic, intercostals or sympathetic nerves, located predominantly in the posterior mediastinum. The majority of schwannomas are benign, asymptomatic and incidental nding [1]. Malignant transformation is very uncommon [2]. Rare patient of Schwannomas arising from the phrenic nerve and result in diaphragm eventration [3]. Histologically, schwannomas usually consist of slender spindle cells surrounded by reticulin bers and two types of tissue (Antoni A and B) are found [4]. Spindle cell tumors must be rule out, leiomyoma, broma and sclerosing haemangioma being the usual types in this area [5]. In our patient, the chest X ray revealed left diaphragm elevation mimic of diaphragm palsy. After serial examinations, we found the young patient had huge schwannoma. References 1. Roviaro G, Montorsi M, Varoli F, Binda R, Cecchetto A. Primary pulmonary tumours of neurogenic origin. Thorax 1983; 38: 9425 2. Molloy C, Staples ED, Sriram PS. A 59-year-old man with a 10-cm lung mass. Chest 2008; 134: 108891. 3. Moinuddeen K, Baltzer JW, Zama N. Diaphragmatic eventration: an uncommon presentation of a phrenic nerve schwannoma. Chest 2001; 119: 16156 4. Thorac. Cardiovasc. Surg. 1983; 3136 5. Eur Respir. J. 1990; 3: 2347

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A HUGE LUNG MASS MIMIC WITH DIAPHRAGM PALSY: A CASE REPORT CHENG-YU CHANG, SHIN-LUNG CHENG, YI-CHAN CHANG, SHIH-CHIEH CHANG Chest Medicine, Far Eastern Memorial Hospital, 21, Nan-Ya S. Rd., Sec. 2 Pan-Chiao, Taipei, Taiwan Introduction Neurogenic tumors can originate in any neurogenic structure in the mediastinum, including sympathetic or parasympathetic chain, intercostal nerves and spinal ganglia. We reported a young female who had chest pain for two months. Her chest X ray presented as left diaphragm palsy and CT scan showed a huge mass. Results The 38-year-old woman who had intermittent chest pain and back pain for two months. She had experienced progressive exertional dyspnea in recent 2 weeks. A chest radiograph showed elevation of left diaphragm. The chest echo revealed a huge isoechoic tumor above left diaphragm, with thickening wall and heterogeneous consistency. The chest CT scan showed an well-encapsulated, measuring 14 10 9 cm in size, heterogeneous mass over left lower lung eld. She received tumor resection after admission. The pathology reported of tumor is composed of spindle cells with Antoni A nuclear palisading features. Antoni B area with myxoid hypocellularity and is discernible. Immunohistochemically, these spindle cells are diffuse cytoplasmic and nuclear positive for S-100 but negative for CD34, actin, desmin. The whole pictures are compatible with an ancient schwannoma.

CASE STUDY COMPOSITE LYMPHOMA: A RARITY IN FORM A CASE REPORT AND REVIEW OF THE LITERATURE SHERLYN CORPUZ, RAMON RIBU, MILAGROS BAUTISTA, ANJANETTE DE LEON Philippine Heart Center, Quezon City, Philippines The simultaneous occurrence of Hodgkins and non-Hodgkins lymphoma, also termed as composite lymphoma, in a single lymph node is an extremely rare condition, as substantiated in literatures. The acknowledged denition of composite lymphoma is the rare occurrence of 2 or more morphologically and immunophenotypically distinct lymphoma clones in a single anatomical clones in a single anatomical site. In this article, we report a fteen year old female with such rare disease. The patient presented with two month history of cough, easy fatigability and chest heaviness. Chest roentgenogram demonstrated a complete opacication of the left hemithorax with contralateral shifting of the mediastinal structures and an anterior superior mediastinum with lobulated margins, considering anterior mediastinal mass. This was established by doing a chest computed tomography. Patient underwent chest thoracotomy and tumor debulking of the anterior mediastinal mass. Biopsy revealed mixed large B-cell Non-Hodgkin and Hodgkins Lymphoma. Patient was treated as an aggressive form of lymphoma and was given high dose chemotherapy.

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EFFICACY AND TOXICITY CISPLATIN BASED COMBINATION CHEMOTHERAPY IN NON-SMALL CELL LUNG CANCER PERSAHABATAN HOSPITAL JAKARTA 2009 NINA MARLINA, ELISNA SYAHRUDIN, ACHMAD HUDOYO Persahabatan Hospital, University of Indonesia, Division Pulmonology, Indonesia Introduction Cisplatin is one the most potent chemotherapy drugs widely used for lung cancer. From metanalysis results cisplatin have efcacy superior than carboplatin, survival rate cisplatin 11% longer than carboplatin. Toxicity cisplatin more in nonhematology (gastrointestinal) than hematology toxicity. In Indonesia carboplatin based regiment most used for non-small cell lung cancer The goals of this study to evaluate efcacy and toxicity cisplatin based regiment. Methods The study was performed a longitudinal observational in non small cell lung cancer treated with cisplatin base combination chemotherapy. Response was evaluated every month and toxicities were evaluate every week after rst time chemotherapy. Results From 50 patients with non-small cell lung cancer, only 30 patients eligible inclusion criteria. There were man (n = 21) and women (n = 9), histology type adenocarcinoma (n = 22), squamous cell carcinoma (n = 6) and large cell carcinoma (n = 2). Thirty patients in advanced non-small lung cancer stage IIIB (n = 9), stage IV (n = 21) were given cisplatin 60 mg/m2 and etoposide 100 mg/m2. Average chemotherapy cycles was 4 cycles (range 2 cycles6 cycle). There were 60% (n = 18) stable disease in objective response. The median survival rate 104 days. Hematologic toxicity include grade 1 of anemia (30%), grade 2 of anemia (20%) and grade 1 of leucopenia (6.7%), grade 2 of leucopenia (3.3%) and grade 3 of leucopenia (6.7%). Nonhematologic toxicity consisted of gastrointestinal toxicities grade 1 (93.3% of), grade 2 (6.7%) and grade 3 of alopesia (100%) Conclusion Cisplatin based combination still effective used as regimen rst line chemotherapy in advanced stage non-small lung cancer. Hematologic and nonhematologic toxicity still tolerable and appropriate with the efcacy chemotherapy.

MASPIN AND DELTANP63 EXPRESSION IN OPERABLE NON-SMALL CELL LUNG CANCER (NSCLC) MIN KI LEE Pusan National University Hospital, South Korea Introduction The aims of this study were to assess the correlation between maspin, p63 and deltaNp63 isoform and to determine the clinical value of its expression in non-small cell lung cancer. Methods A total of 92 patients with surgically conrmed NSCLC, including 47 cases of squamous cell carcinomas (SCCs) and 45 cases of adenocarcinomas (ADCs) were analysed. The immunohistochemical stain with maspin, p63 and deltaNp63 was performed using tissue microarray blocks. Results Maspin was expressed in 76.6% of SCCs tissues and 15.5% of ADCs respectively. The rate of p63 expression was 91.4% in SCCs and 22.2% in ADCs. Maspin expression was correlated with p63 in SCCs and with deltaNp63 in SCCs. Conclusion Maspin was exclusively expressed in SCCs and had a strong correlation with p63 and deltaNp63 in SCCs. DeltaNp63 was not an independent prognostic factor for NSCLC.

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SURGICAL TREATMENT FOR SECOND LUNG CANCER

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THE FEASIBILITY FOR WHOLE BODY MRI TO DETECT BONE METASTASES IN PULMONARY EPITHELIOID HEMANGIOENDOTHELIOMA CASE REPORT HYO JIN HAN, YANG KEUN RHEE, CHI RYANG CHUNG, SEUNG YOUNG SEO, SEOUNG JU PARK, KYUNG HOON MIN, SO RI KIM, MIN HEE LEE, YONG CHUL LEE, HEUNG BUM LEE Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, South Korea Introduction Pulmonary epithelioid hemangioendothelioma (PEH) is a rare malignant disease, with less than 100 cases described in the literature. This tumorous condition can metastasize to multiple organs, and has variable prognosis that is unpredictable. This report can support to the superiority of WB-MRI on detecting bone metastases even in negative ndings of PET/CT or bone scan in PEH. A 48-year-old woman was referred to our hospital due to radiologic abnormality with complaining of cough and back pain. She was diagnosed as having gastritis. A routine chest X-ray showed a localized soft tissue mass density on right lower lung. Physical examination and laboratory data were nonspecic. The working diagnosis was that of a lung malignancy or pulmonary tuberculosis. A contrast enhanced CT of thorax revealed three nodules on a 3 2 cm sized heterogenous enhanced mass with internal calcications on right segment (RS) 9, and less than 1 cm sized two small nodules on LS 3 and RS 5. A diagnostic bronchoscopy disclosed a luminal narrowing of RB8 & 9 due to hyperemic elevated mucosa with easy contact bleeding. Bronchoscopic biopsy did not provide a diagnosis. The lung tissues obtained by percutaneous transthoracic needle biopsy (PTNB) demonstrated PEH, and which was conrmed by immunohistochemistry. On PET/CT, the lung lesions, and left 8th, 9th ribs and right proximal femur showed increased uorodeoxyglucose (FDG) uptake. Additional bone metastases on thoracic and lumbar spine were detected by Whole body MRI (WB-MRI). Right bi-lobectomy and concurrent mediastinal lymph node dissection were performed. Following the operation, palliative radiotherapy was performed for the control of back pain diagnosed bone metastasis by WB-MRI.

TANEL LAISAAR, EERO JAKOBSON, KRT URGAND Department of Thoracic Surgery, Tartu University Lung Hospital, Tartu, Estonia Introduction Lung cancer has remained an important clinical problem. During recent years the frequency of second primary lung cancer in patients previously undergone radical surgery seems to have increased. The aim of the current study was to analyze second primary lung cancer occurrence and surgical treatment results. Methods From January 2007 to January 2010 in our department 194 radical cancer operations were performed, incl. 12 (6.2%) cases (10 males and 2 females) of second primary lung cancer. Data of these patients were analyzed retrospectively. Results One of the patients had two synchronous cancers in same lobe and those were removed during the same operation. In other cases interval between the two operations varied from 3 months to 10.5 years (median 4.1 years). The rst cancer was squamous cell cancer in 9, adenocarcinoma in 2 and small-cell cancer in 1 patient; the second cancer was squamous cell cancer in 4, adenocarcinoma in 5 and parvocellular, large cell and anaplastic cancer in 1 patient each. Lobectomy was performed as the rst operation in 9, wedge resection in 2 and pneumonectomy in 1 patient. As the second operation lobectomy was performed in 6, segmentectomy in 2, wedge resection in 3 and completion pneumonectomy in 1 case. Nine patients had been smokers and 3 ex-smokers before the rst operation. Only 2 patients quit smoking after their rst cancer operation. Mean FEV1 before the rst and the second operation was 2.83 and 2.19; FVC was 3.70 and 3.06, respectively. Surprisingly, the median duration of rst hospitalization was 12 days and of second hospitalization 9 days only, although we experienced prolonged postoperative air-leak in 1 case after the rst and in 3 cases after the second operation. Arrhythmia was observed in 1 patient after the rst operation and COPD exacerbation requiring mechanical ventilation in 1 patient after the second operation. No other complications or mortality occurred. Nine patients are currently alive; 3 patients died 4 months to 1.5 years after the second operation. Conclusion Second primary lung cancer after rst radical cancer operation is relatively common and in selected cases can be surgically treated with results similar to the rst operation.

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THE OTHER SIDE OF THE COIN: ADENOCARCINOMA OF THE LEFT LUNG PRESENTED AS A SOLITARY PULMONARY NODULE MARIA ELIZABETH MENDOZA, AILEEN BANZON Division of Pulmonary and Critical Care Medicine, Philippine Heart Center, Quezon City, Philippines Introduction This is a case of 73 years old, Filipino, male, who presented with a solitary pulmonary nodule admitted for elective surgery for repair of hernia. He is nonhypertensive non diabetic with a previous history of PTB treatment. On physical Examination revealed unremarkable. A CXR was done and revealed a fairly dened solitary pulmonary nodule in the left mid lung devoid of calcication. Thus he was advised to do chest CT scan. a Chest CT scan with biopsy was done and revealed Adenocarcinoma of the left lung. He was then advised to sought consult to a pulmonologist and he was advised to do PET Scan for staging. Eventually PET Scan was done and revealed stationary noncalcied, mildly hypermetabolic speculated pulmonary nodule with satellite lesion, lingual area, no noted metastasis to other organ. He was then advised elective thoracotomy, for lobectomy of the left upper lobe. Methods Pulmonary solitary nodule of the lung is a single, spherical, wellcircumscribed, radiographic opacity that measures 3 cm in diameter and is surrounded completely by aerated lung. There are no associated atelectasis, hilar enlargement, or pleural effusion. Most lung nodules are detected incidentally on CXRs or CT scans. Prevalence of malignancy in patients with SPN varies widely across studies. Prevalence of malignancy PET scan = 46 to 82%. SPN is important because malignant nodules represent a potentially curable form of bronchogenic carcinoma. Results An elective thoracotomy was done and revealed adenocarcinoma of the left lung. PET scan is a noninvasive functional imaging test that is widely used in clinical oncology for tumor diagnosis, disease staging, and evaluation of treatment response characterized pulmonary nodules with fairly high sensitivity (80 to 100%) and variable specicity (40 to 100%).

ERLOTINIB FOR JAPANESE PATIENTS WITH RELAPSED SQUAMOUS CELL CARCINOMA OF THE LUNG AKITO HATA, KUNIMASA KEI, YOSHIOKA HIROSHIGE, FUJITA SHIRO, KAJI REIKO, TACHIKAWA RYO, TOMII KEISUKE, ISHIDA TADASHI, KATAKAMI NOBUYUKI Institute of Biomedical Research and Innovation, Japan Introduction The efcacy of getinib is mostly limited to patients (pts) with EGFR mutations. Conversely, erlotinib (E) demonstrated efcacy in pts with not only EGFR mutations but also squamous cell carcinoma (SCC), revealed in the subset analysis of BR.21 and SATURN trials. Methods We retrospectively researched the efcacy and toxicity of E as the 1st-TKI for 30 pts with relapsed SCC. Results Response rate and disease control rate (DCR) were 7% and 37%, respectively. Median progression free survival (mPFS) and overall survival were 1.2 months and 11.0 months, respectively. EGFR mutations were found in two of 30 cases (7%), and both of them achieved stable disease. E-inducedinterstitial pneumonia (grade 5) was observed in only one patient. Subset analysis reafrmed the high predictive value of a skin rash, grade 2 or higher. In pts with grade 0 or 1 skin rash, DCR and mPFS were 18% (3 of 17) and 1.0 months, while in those with grade 2 skin rash or higher, advanced to 62% (8 of 13) and 3.4 months (DCR: p = 0.023) (PFS: p = 0.0056). Conclusion Especially in pts with a severe skin rash, high disease control rate can be expected with E for relapsed SCC of the lung.

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A CASE OF METASTATIC TUMOR IN THE LUNG DIAGNOSED BY IMMUNOHISTOCHEMISTRY ERLANG SAMOEDRO, ELISNA SYAHRUDIN, ACHMAD HUDOYO, HERIAWATY HIDAYAT Persahabatan Hospital, University of Indonesia, Division Pulmonology, Indonesia Introduction Pulmonary metastasis represents the dissemination of cancer cells with establishment of local residence in the pulmonary parenchyma. Pulmonary metastases are common because the entire output of the right heart and the lymphatic system ow through the pulmonary vascular system. Examples of such metastases include renal cancers, bone sarcomas, choriocarcinomas, melanomas, testicular teratomas, and thyroid carcinomas. Most pulmonary metastases arise from common tumors, such as breast, colorectal, prostate, bronchial, head-and-neck, and renal cancers. The detection of pulmonary metastases is crucial in the treatment of patients with cancer. Methods Case report female 46 years old underwent colostomy because of tumor in colorectal 12 years ago, never took chemotherapy before and came to hospital with chief complain paraparesis, and shortness of breath. Chest x ray was performed and showed pleural effusion in the left hemithoraks, thoracocentesis was performed and showed redish and exudative uid. Thorax CT Scan showed tumor in the central left lung with atelectasis and compression of vertebra Th 1. Abdomen CT showed no mass and no lymph enlargement in the abdomen, no sign of metastasis in the abdomen. Bone survey was performed and showed metastasis in vertebra Th 1,3 with rib bone no 12 destruction. The seromarker showed elevated CEA. Bronchoscopy was performed and the result was adenocarcinoma mucinosum, to distinguish between primary lung tumor or metastatic tumor in the lung we performed TTF1 immunohistochemistry staining, the result was negative TTF1. Results In this patient TTF1 immunohistochemistry staining was performed to distinguished between primary lung tumor or metastatic tumor in the lung. TTF1 was a reliable marker for differential diagnosis in distinguishing primary adenocarcinomas of the lung from extrathoracic origins marker for adenocarcinoma. Conclusion We conclude that the tumor in the lung was metastatic tumor, the patient underwent chemotherapy with cisplatin based and radiotherapy for the metastatic tumor in the vertebra.

Conclusion Thus even with a benign looking pulmonary solitary nodule can be an invasive cancer, if not aggressively manage and evaluated by a noninvasive modalities such as a PET scan.

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ARE LEVELS OF PRO-GASTRIN-RELEASING PEPTIDE OR NEURON-SPECIFIC ENOLASE AT RELAPSE PROGNOSTIC FACTORS AFTER RELAPSE IN PATIENTS WITH SMALL-CELL LUNG CANCER? TAKASHI HIROSE, KENTARO OKUDA, TOSHIMITSU YAMAOKA, SOJIRO KUSUMOTO, TOMOHIDE SUGIYAMA, TAKAO SHIRAI, MASANAO NAKASHIMA, TSUKASA OHNSHI, MITSURU ADACHI Division of Respiratory Medicine and Allergology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa, Tokyo, Japan Introduction The purposes of this study were to assess the relationship of serum levels of pro-gastrin-releasing protein (ProGRP) and neuron-specic enolase (NSE) at relapse with survival after relapse and the response to salvage therapy and to assess whether serum levels of ProGRP and NSE at relapse are useful markers for detecting relapse earlier than are symptoms or radiographic ndings in patients with small-cell lung cancer (SCLC). Methods The subjects of this study were 103 patients with SCLC who had achieved a complete response (CR) or partial response (PR) to rst-line chemotherapy. We retrospectively evaluated whether ProGRP or NSE increased earlier than symptoms or radiographic ndings appeared, and the association between response to salvage therapy and levels of ProGRP or NSE at relapse. In addition, we evaluated the association between survival after relapse and clinical and demographic factors at relapse, including age, sex, response to rst-line treatment, sensitivity to rst-line treatment, stage, performance status (PS), and serum levels of ProGRP, NSE, and lactate dehydrogenase. Results At relapse, 69.3% of patients had elevated serum levels of ProGRP, 60.2% had elevated serum levels of NSE, and 81.3% had elevated serum levels of either ProGRP or NSE. However, almost all asymptomatic relapses were detected with radiographic studies. The rate of CR to salvage chemotherapy was signicantly lower in patients with elevated levels of NSE (2.2%) than in patients without (26.7%; p = 0.001). Univariate analysis showed that sensitivity to rst-line treatment, serum levels of NSE, stage, and PS at relapse were prognostic factors for survival after relapse. Multivariate analysis showed that sensitivity to rst-line treatment, serum levels of NSE, and PS at relapse were independent prognostic factors after relapse. Conclusion In conclusion, serum levels of ProGRP and NSE at relapse are not useful markers for detecting relapse earlier than are symptoms or radiographic ndings. On the other hand, the serum level of NSE at relapse is a useful predictive marker for CR to salvage chemotherapy and a useful prognostic factor after relapse in patients with SCLC who have achieved a CR or PR to rst-line chemotherapy.
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SPONTANEOUS PNEUMOTHORAX ASSOCIATED WITH ERLOTINIB IN PRIMARY NON-SMALL CELL LUNG CANCER SEUNG MIN KWAK, HAE SEONG NAM, JAE WHA CHO, JEONG SEON RYU, HAE SEONG NAM Internal Medicine Pulmonary Division, Inha University Hospital, 7-206, 3-GA, Sinheung-Dong, Jung-Gu, Incheon, South Korea Introduction Spontaneous pneumothorax (SP) associated with primary lung cancer is quite rare, but has been reported as the initial presentation or a complication of disease progression. However, SP associated with chemotherapy in primary lung cancer patients occurs at a low frequency, accounting for less than 0.05% of all cases. Methods Here, we report the rst case of SP associated with erlotinib in a patient with primary non-small cell lung cancer. Results After three cycles of cisplatin-based chemotherapy as rst-line therapy, erlotinib was administered as second-line treatment. Asymptomatic SP accompanied by a signicant decrease in the size of the tumor was observed in the left lung 7 weeks later. The patient recovered without any therapeutic intervention, despite continued administration of erlotinib. Conclusion This case shows that SP can occur in primary lung cancer patients receiving erlotinib, and asymptomatic SP associated with chemotherapy in primary lung cancer patients may not require therapeutic intervention.

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PRIMARY MEDIASTINAL GERM CELL TUMORS A RETROSPECTIVE REVIEW OF CLINICAL FEATURES AND BIOLOGIC CORRELATION OF PATIENTS DIAGNOSED WITH PRIMARY MEDIASTINAL GERM CELL TUMORS AT THE LUNG CENTER OF THE PHILIPPINES FROM 19992008 RHODA BABALO, GUIA ELENA IMELDA LADRERA Department of Pulmonary Medicine, Lung Center of the Philippines, Quezon City, Philippines Introduction Primary Malignant Mediastinal Germ Cell Tumors are uncommon, comprising 2%5% of the mediastinal tumors but are important because they occur in very young patients at the prime of their lives. There were few reports on the clinical outcome after therapeutic challenge for these type of tumors. Methods Retrospective review of medical records of admitted patients diagnosed with primary mediastinal germ cell tumors from January 1999 December 2008. Results Records of 34 patients with mean age of 24 years 6.7 years with 10:1 M : F ratio on their second and third decade of life were reviewed. Majority complained with dyspnea (38.23%), cough (32.35%), SVC (17.64%) and asymptomatic (11.76%). Five patients have seminomatous GCT and 29 patients have non seminomatous GCT. Among the non seminomatous GCT, 14 were malignant teratoma, 12 yolk sac tumor, 2 have choriocarcinoma and 1 embryonal CA. Most patients were diagnosed histologically through PNLB (50%), thoracotomy (17.64%), mediastinotomy (17.64%) and CNB (14.70%). Recurrence after 1 year correlated with levels of alpha feto protein at diagnosis and was statistically signicant (p = 0.0487). Normal levels of alpha feto protein at diagnosis have less chances of recurrence after one year as compared with patients with elevated levels once diagnosis has been made. However, it does not correlate well with Beta HCG (p = 0.175), and LDH (p = 0.529). Also, recurrence was not affected by the treatment instituted initially (p = 0.662), sex of patient (p = 0.295) and age (0.1192). Conclusion This study conrms that mediastinal germ cell tumors were mostly seen in patients in rst and second decade of their lives with male predominance. Majority were symptomatic and dyspnea was the most frequent symptom. Mostly were diagnosed by percutaneous needle lung biopsy. The tumor marker commonly elevated with seminomatous germ cell tumor was Beta HCG while alpha feto protein in non seminomatous germ cell tumor. Lactate Dehydrogenase cannot be used as a marker for these tumors. Normal levels of alpha feto protein at diagnosis have less chances of recurrence after 1 year however, it does not correlate with Beta HCG and LDH as well as other parameters such as treatment instituted initially, sex, and age of the patient.

SURVIVAL ANALYSIS AMONG LUNG CANCER PATIENTS IN PAHANG TECK HAN NG, SOON HIN HOW, YEH CHUUN KUAN, AR JAMALLUDIN, AR FAUZI International Islamic University Malaysia, 49 Lorong Seri Teruntum 12 Taman Kiara 25100, Kuantan Pahan, Malaysia Introduction Lung cancer is the most common cause of cancer mortality worldwide, including Malaysia. There were limited data on survival of lung cancer patients in Malaysia. Methods A prospective study was conducted from November 2007 to November 2009. Patients with histology conrmed lung cancer were recruited in the study. Survival time was dened from the date of histological diagnosis to time of death. Data on patients characteristic, ECOG functional status, staging, treatment were obtained. Kaplan Meier was used to measure the survival status and compared using log-rank test. Relevant factors were included in Cox Proportional Hazard Regression to identify independent factors affecting the survival of lung cancer patient. Results Of a total of 100 patients enrolled in this study, 81% were males and 82% were smokers. The age ranges from 30 to 83 years with mean (SD) age of 59.6 (11.3) years. There were 68 Malays, 27 Chinese, 3 Indians and 2 Arbogines. ECOG of 0 or 1, 2 and 3 or 4 were found in 47%, 19% and 34% respectively. All patients presented with either stage 3 or 4 (47% in stage 4). Only 45% patients received conventional chemotherapy. Overall, median (SE) survival was 14.8 (3.5) weeks. There were no signicant differences in median survival among males vs females, smokers vs non-smokers, Malays vs nonMalays, stage 3 vs stage 4. However, patients with ECOG 0 or 1 had longer median survival than patients with ECOG 2 or more (35.3 week vs 8.9 weeks, p < 0.001). Patients given chemotherapy also had longer median survival than those without chemotherapy (37.4 weeks vs 4.9 weeks, p < 0.001). On multivariate analysis, when all these factor were included in the regression model, only smoker and patients on best supportive care alone were the signicant independent negative prognostic factors affecting survival. Conclusion Patients of good performance status of ECOG 0/1 and given chemotherapy were associated with better survival in lung cancer patients.

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CHEMOTHERAPY-INDUCED NEUTROPENIA AS A PROGNOSTIC FACTOR IN PATIENTS WITH ADVANCED NON-SMALL CELL LUNG CANCER TREATED WITH MORE THAN 4 CYCLES OF FRONT-LINE PLATINIUM-BASED CHEMOTHERAPY SUN YOUNG KIM, LEE JEONG EUN, YOO SU JIN, JUNG SUN YOUNG, SHIN JI YOUNG, PARK JI WON, PARK HEE SUN, KIM JU OCK Chungnam National University Hospital, Daejeon, South Korea Introduction Neutropenia is a common side effect of platinium-based chemotherapy. We analyzed the association between the grade of chemotherapyinduced neutropenia and the clinical outcome for patients with advanced non-small-cell lung cancer (NSCLC). A possible explanation for the association is that the absence of neutropenia may suggest a lack of efcacy of the administered chemotherapy regimen possibly due to pharmacogenetic reasons and varied metabolism of anticancer drugs. Methods Thirty nine patients with locally advanced/metastatic NSCLC, treated with front-line more than 4 cycles of platinium based chemotherapy were retrospectively analyzed. The mean number of cycles of front-line chemotherapy they were treated was 5.8. Patients were categorized into two groups according to the presented worst neutropenia grade: mild (grades I/II) and severe (grades III/IV). Results One year survival was signicantly better in patients developing severe grade of neutropenia compared with those with mild neutropenia; the 1 year survival rate were 18.2% (2/11), 60.7% (17/28) for the groups with mild and severe neutropenia, respectively (p value = 0.017). The median overall survival were 8.4, 20.4 months for the same groups, respectively. The disease controlled rate (including complete remission, partial response and stable disease) was better in patients with severe grade of neutropnenia; 45.5% (5/11) and 60.7% (17/28) for the groups with mild and severe neutropenia, but there was no statistical signicance (p value = 0.387). Conclusion Chemotherapy-induced neutropenia can be a predictor of better clinical outcome for patients with advanced NSCLC.

THE CLINICOPATHOLOGIC FEATURE OF HUMAN PAPILLOMAVIRUS INFECTION AND E6 ONCOPROTEIN IN LUNG CANCER PATIENTS DAE SUNG HYUN, SANG CHAE LEE, KYUNG CHAN KIM Catholic University of Daegu, Daemyung-dong 3056-6, Nam-gu, Daegu, South Korea Introduction The high-risk strains of human papilloma virus (HPV) have been identied in human neoplasm of cervix, skin, head and neck, esophagus and lung. This study was performed to evaluate the prevalence of HPV infection and E6 oncoprotein in lung cancer patients. Methods HPV DNA chip method for detection and genotyping of various HPV and immunohistochemical stain of E6 oncoprotein were performed in 72 patients with lung cancer who underwent curative surgery from March 2006 to November 2008 in Daegu Catholic University Hospital, Daegu, Korea. Results The median age was 66 years and the proportion of male is 70.8%. 40 patients were histology of adenocarcinoma, 28 patients were histology of squamous cell carcinoma, 2 patients were histology of mixed type (Adenocarcinoma and squamous cell carcinoma), 1 patient was histology of Large cell carcinoma and 1 patient was histology of small cell carcinoma. The prevalence of HPV positive lung cancer is 8.3% (6 patients, 3 squamous histology and 3 adenocarcinoma histology) and all of those patients have 16 HPV subtype. HPV E6 oncoprotein was expressed in 32.8% of patients. Statistical analysis revealed that the prevalence of expression of HPV E6 oncoprotein was signicantly high in female patients. Conclusion This study showed that the prevalence rate of HPV 16 infection in lung cancer tissue of curative surgical resection was 8.3% and HPV E6 oncoprotein was expressed in 32.8% of patients, suggesting HPV 16 infection played an important role in lung carcinogenesis of Koreans.

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LUNG RADIOLOGY OF ATELECTASIS SECONDARY TO MUCOID SECRETION MIMICKING LUNG MALIGNITY: A CASE REPORT CANTRK TASCI, DENIZ DOGAN, HAYATI BILGIC Gulhane Medical School, Department of Chest Disease, Ankara, Turkey Case Report 58 years old male patient admitted to our clinic with dyspnea and back pain. Riegraphy (Figure 1) revealed nearly total left lung atelectasis and left mediastinal shift. Thoracal computerized tomography (CT) performed. CT signs (Figure 2) including volume loss of left hemithorax, atelectasic left lung and pleural effusion lead us to perform bronchoscopy. The primary diagnosis was lung malignity. There was no endobronchial lesion but existing extensive mucoid secretion starting from left main bronchus was aspirated (Figure 3). Post-bronchoscopy riegraphy revealed nearly total expanded lung (Figure 4). We reported a case who had atelectasis secondary to mucoid secretion due to loss of cough reex related with severe back pain mimicking primary lung malignity.

HISTOPATHOLOGIC DIAGNOSIS AND CLASSIFICATION BY BRONCHIAL BIOPSY OF LUNG CANCER GONENC ORTAKOYLU, AYSE BAHADIR, NESLIHAN FENER, NUR BUYUKP Yedikule Chest Hospital-Istanbul/Turkey, Turkey Introduction Different histological subtypes of lung cancer has important role for assessment of prognosis and the planning of treatment. Our objectives are diagnosis of lung malignance in the bronchial biopsy and to nd out how often the term non-small cell carcinoma. Methods We assessed 894 bronchial biopsy specimens. Pathology records were evaluated for clinical preliminary approach, histopathologic diagnosis and interpretation, immunohistochemistry applications. Results Cases had squamous cell carcinoma 272 (30.40%), adenocarcinoma 48 (5.36%), small cell carcinoma 46 (5.14%), non-small cell carcinoma 334 (37.36%), carcinoid tumor 13 (1.45%), round cell malign tumor 170 (19.01%), other tumors 11 (1.23%). 50 patients with nonsmall cell carcinoma were guested histological subtype. 274 tumors were done immunohistochemistry. Conclusion Denite cell typing by bronchial biopsy in lung malignance may be extremely difcult. Term for non-small cell carcinoma and round cell malign tumor can be used when morphologic ndings in biopsy are insufcient.

Figure 1

Figure 2

Figure 3 Figure 4

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MULTIPLE PULMONARY SCLEROSING HEMANGIOMAS OF UNILATERAL LUNG MIMICKING METASTATIC LUNG CANCER A CASE REPORT SHIH-PIN CHEN, CHEAU-FENG LIN, MING-CHIH CHOU, CHANG-YAO TSAO Internal Medicine, Chung Shan Medical University & Chung Shan Medical University Ho, No. 110, Sec. 1, Chien-Kuo N. Road, Taichung, Taiwan Introduction Pulmonary sclerosing hemangioma (PSH) is a rare benign tumor usually presenting as a peripheral and solitary nodule of less than 3 cm in diameter, predominantly in the lower lobe in asymptomatic middle-aged women. Multiplicity is very rare. In this report, we present a case of multiple PSHs of unilateral lung in a twenty-year-old young man. The diagnosis, therapeutic management, and outcomes are discussed. In addition, the literature is also reviewed. Methods We report a 20-year-old, non-smoking asymptomatic young man who was referred due to chest radiograph showed multiple nodules in the left lung in routine health examinations. Under the impression of metastatic lung cancer, computed tomography (CT) scans of the chest was done. It revealed multiple masses, varying from less than 1 cm to 2.7 cm in diameter in both left upper and lower lobes, but none in the right lung. Each lesion was a roundshaped nodule with a distinct margin and homogeneously density. There was no mediastinal lymphadenopathy. CT-guided biopsy failed to make a denite diagnosis. So he underwent a video-assisted thoracoscopic surgery in order to get a denite pathological diagnosis. The frozen section of biopsies during surgery impressed pulmonary sclerosing hemangioma. Therefore, left lower lobe wedge resection was performed only. He was discharged without any complications four days after operation. Results Sclerosing hemangioma of the lung is a relatively rare benign tumor rst described by Liebow and Hubbell in 1956. Histologically, there is a mixture of solid, sclerotic, papillary and hemorrhagic components in typical cases. Recent studies suggest that sclerosing hemangioma derives from primitive respiratory epithelium and demonstrates neoplastic differentiation. The majority of PSH present as a solitary pulmonary nodule, whereas multiple lesions are reported to account for only 4% of all cases. By the observation from previous reports, multiple PSH were slow-growing. Since pathology proved benign lesions and the necessary of invasive surgery of pneumonectomy is controversial, the patient is kept on observation after VATS surgery. Conclusion Multiple PSHs should not be misdiagnosed because of its favorable outcome.

LEFT BOCHDALECK HERNIA IN ADULT: A CASE REPORT CHARIZA HALUN, RUBY NOLIDO, ANDRE ANGELO TANQUE, ALBERT ALBAY JR Pulmonary Section, Department of Medicine, University of the PhilippinesPhilippine General Hospital, Philippines Introduction Left Bochdalek hernia is a complex condition with high mortality. In most cases, it presents in the neonatal period and is seldom found later in life with symptoms, the prognosis is excellent. Methods 33-year old, Filipina with a history of cough and epigastric pain, initially treated for pneumonia and acid peptic disease. Chest imaging showed bowel loops and mesentery above the elevated Left hemidiapragm with mediastinal shift. Surgical repair was done. Exploration demonstrated defect at the Left posterolateral diaphragm without a hernia sac; incarcerated small bowel. She was then discharged improved with plans of close outpatient follow-up.

Results Bochdalek Hernia results from the herniation of the abdominal organs through a congenital defect of the posterior diaphragm occurring due to the failure of the pleuroperitoneal canals to close. The hernia tends to occur more often on the left side because the right pleuroperitoneal fold fuses earlier than the left and. Diagnosing this condition in the adult is rather difcult. In the adult type hernias, abdominal symptoms are seen more frequently than the pulmonary symptoms. Clinical presentation of delayed left Bochdalek hernia is not specic and the diagnosis is often overlooked. The prognosis is excellent and mostly depends on the time of diagnosis. Acute abdomen develops in the existence of the strangulation or obstruction. This is a case of left Bochdalek hernia with delayed presentation of epigastric pain and dyspnea. Conclusion Surgical repair is mandatory due to the risk of life threatening complications. Laparotomy with thoracotomy is the standard treatment. In this case a thoracoabdominal approach was done with reduction of abdominal viscera into the peritoneal cavity, and closure of the defect and placement of fascia lata mesh.

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CHYLOUS PLEURAL EFFUSION IN A PATIENT WITH ACUTE MYELOGENOUS LEUKEMIA PRESENTING WITH MULTIPLE LYMPHADENOPATHIES MA PHILINA PABLO, JOEL SANTIAGUEL Section of Pulmonary Medicine, Philippine General Hospital, Taft Avenue, Manila, Philippines Introduction Chylous pleural effusion, or chylothorax, is dened as the accumulation of chyle-containing lymphatic uid within the pleural space. It is usually secondary to disruption of the thoracic duct or its tributaries or derangement of lymphatic ow within the thorax. In a previous series, malignancy was the most common cause of chylothorax in approximately one half of patients with this condition. Among the various malignancies, lymphoma was the most common occurring in three fourths of this group while lung carcinoma was the next most common. Specic hematologic malignancies in adults documented to have occurrence for chylothorax are chronic lymphocytic leukemia, Waldenstrom macroglobulinemia and hairy cell leukemia. Methods We report a case of a 30 year-old female, admitted at our institution, with acute myelogenous leukemia presenting with generalized lymphadenopathy and was found to have chylous pleural effusion. Management options for the patients chylous effusion were presented. Results Management of chylothorax includes therapy of the underlying disease associated with other conservative measures, such as drainage of pleural effusion, maintenance of nutritional condition, and chemical pleurodesis. Surgical therapy is proposed when conservative treatments have failed. Since there has been no documented case of chlothorax in acute myelogenous leukemia, considerations for the management of our patient was based on current available management for malignant cyhlothorax in general. Conclusion Acute myelogenous leukemia with generalized lymphadenopathy is a rare presentation and so far, there has been no documented case of acute myelogenous leukemia presenting with chylous effusion in an adult patient as in this case. In our patient, optimal management should rst and foremost include treatment of the acute myelogenous leukemia with appropriate chemotherapy which should also address the lymphadenopathies causing obstruction of the lymphatic ow. Various interventions and treatment options for the patients chylothorax has been presented. It is, however, the patients nal decision which was carried out.

HORNERS SYNDROME: AN EXTREMELY RARE COMPLICATION OF TUBE THORACOSTOMY KUTHAN KAVAKLI, HAKAN ISIK, ORHAN YUCEL, ERSIN SAPMAZ, SEDAT GURKOK, HASAN CAYLAK, SEZAI CUBUK, ALPER GOZUBUYUK, ONUR GENC Gulhane Military Mediacl Acaolemy (GMMA), Aukara, Turkey Introduction Chest tube insertion is the most common procedure in the thoracic surgery practice. This surgical procedure are including various complications however Horners syndrome results from compression of the stellat ganglia due to apical insertion of chest tube is extremely rare. Results A 21-year-old man has admitted with the complaint of chest pain and dyspnea. The breath sounds decreased at the left side and chest X-ray conrmed spontaneous pneumothorax. A 28 gauge chest tube was inserted through the fth intercostal space in the anterios axillary line and connected to underwater seal. After chest tube insertion his lung expanded and there was no air leak. The computerized thorax tomography, was performed for the evaluation of bullae, revealed the apical placement of the tip of chest tube (Figure 1). We removed his chest tube on the 4th day, however he was noted to have ptosis and miosis on the left side. The compression time of stellat ganglia via tip of chest tube was determined as four days. After three weeks he admitted to another Thoracic Surgery Department with the same symptoms and recurrence spontaneous pneumothorax was determined. Then he underwent left axillary thoracotomy for the resection of bullae. There was a slight pytosis at three months follow up.

Figure 1

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EFFICACY OF AUTOLOGOUS BLOOD PATCH PLEURODESIS FOR INOPERABLE SYNCHRONOUS BILATERAL SECONDARY PNEUMOTHORAX TAKASHI ADACHI, HIDEO SAKA, MASAHIDE OKI, CHIYOE KITAGAWA, YOSHIHITO KOGURE, NAOHIKO MURATA, MISAKI RYUGE, RIE TSUBOI, SAORI OKA Department of Respiratory Medicine, Nagoya Medical Center, Nagoya, Japan Introduction Synchronous bilateral pneumothorax with persistent air leak is rare, but occasionally it may result in fatality. We evaluated the efcacy and safety of an autologous blood patch as an alternative method for inoperable synchronous bilateral secondary pneumothorax. Methods We treated 492 pneumothorax patients at the Department of Respiratory Medicine, Nagoya Medical Center between January 1999 and December 2009. We retrospectively analyzed patients with inoperable synchronous bilateral pneumothorax treated with the autologous blood patch. Results There were 14 synchronous bilateral pneumothorax patients. Seven (6 males and 1 female) were treated with autologous blood patch. They ranged in age from 32 to 81 years (mean age, 63 years). The types of underlying disease were COPD in 4 patients, interstitial pneumonia in 2 patients, and LAM in 1 patient. All patients had severe lung disease, and were not good candidates for operation. The median number of pleurodesis was 3 times (range 27). After 24 hours with no air leakage, we could remove the chest tube in 6 patients (86%). The other patient suffered from persistent air leakage, and resulted in death. Recurrence of pneumothorax occurred in 3 patients. Although 2 patients were treated successfully by thoracostomy only, 1 still had persistent pneumothorax and died of respiratory failure despite Endoscopic Watanabe Spigot (EWS) treatment. Conclusion The autologous blood patch is an effective and convenient option for synchronous bilateral secondary pneumothorax.

Conclusion The recovery of the HS caused by chest tube insertion is closely related with compression time of stellat ganglia and the patients should be closely followed up particularly in patients with apical placement of chest tube.

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UNDETERMINED LEFT FALLEN LUNG SEDAT GURKOK, HASAN CAYLAK, ORHAN YUCEL, ERSIN SAPMAZ, ALPER GOZUBUYUK, SEZAI CUBUK, HAKAN ISIK, ONUR GNEC, KUTHAN KAVAKLI Gulhane Military Medical Academy (GMMA), Ankara, Turkey Introduction The fallen lung is described as the peripheral displacement rather than the usual central displacement of the collapsed lung. This is usually the result of complete or parsial rupture of a bronchus. Tracheobronchial rupture is reported in less than 1% of patients with blunt trauma. Persistent air leak despite a correctly placed. Results A 20-year-old man has admitted with complaining of dyspnea. X-ray revealed mediastinal shift, tracheal deviation, parenchymal herniation and left pneumonectomy cavity. Tomographic appearance of right lung hypertrophy and herniation to the left side. However, contrast enhanced CT revealed soft tissue density in the left postero-inferior thoracic cavity. He had a history of blund chest trauma when he was 12 years old. Surprisingly right posterolateral thoracotomy incision was determined on his physical examination. When the mediastinal pleura is intact, the symptoms are very rare and the lung is expanded. Therefore this clinical condition can be missed very easily at the rst admission. Conclusion It is very important to get chest X-ray after one week from trauma in order not to miss fallen lung.

CHARACTERISTIC AND INPATIENT MORTALITY RISK FACTORS OF MEDIASTINAL MASS IN CIPTO MANGUNKUSUMO HOSPITAL GURMEET SINGH, ZULKIFLI AMIN, CLEOPAS MARTIN RUMENDE, WURYANTORO, VALLY WULANI Internal Medicine, PAPDI, Indonesia Introduction Mediastinal masses include a wide variety of tumors and remain an interesting diagnostic challenge and therefore, a standardized diagnostic and therapeutic workup is instrumental. There are no reports concerning the characteristics and inpatient mortality risk factors of mediastinal mass in Cipto Mangunkusumo Hospital, Jakarta. This study presents the characteristic, the histological types and inpatient mortality risk factors among 113 patients with primary mediastinal masses diagnosed and treated at the University of Indonesia/Cipto Mangunkusumo Hospital over a 10 year period. Methods This was a retrospective case control study conducted on 113 patients with mediastinal masses over a 10-year period 20002009 in our institute. Results A total of 113 patients with mediastinal masses including 69 males 61.1% and 44 females 38.9% with a mean age of 47 years entered the study. Most mediastinal mass 77% were identied in the 1860 age group. As many as 94.7% of patients were symptomatic at presentation. The commonest symptoms in this series were cough 72.6%, dyspnoea 71.7%, and weight loss 53.1%. Mediastinal tumors, accounted most of the mediastinal mass 44.2%. Thymoma 25.0%, thymic carcinoma 6.5%, lymphoma 2.8%, germ cell tumors 2.7% and ganglioneuroma 0.9% were the types of primary mediastinal masses treated. Majority of the tumors had anterior mediastinal presentation 56.6%. CXR detected only 79.2% of CT-demonstrated mediastinal masses in this series. Superior Vena Cava syndrome was seen in 29.2% of the patients. As many as 12.4% of the patients were diagnosed by Trans Thoracal Biopsy, while 37.2% of the patients required thoracotomy for a diagnosis. Inpatient mortality rate of the whole series was 39.9%. We indentied Sepsis, Superior Vena Cava Syndrome, Masive pleural effusion, and Miastenia gravis as inpatient mortality risk factors for mediastinal mass in our series. Conclusion The characteristic and histologic types in our series varied from some previously published reports. Factors associated with inpatient mortality were Sepsis, Superior Vena Cava Syndrome, Masive pleural effusion and Miastenia gravis. This suggests that patients with those factors, might need better attention paid to preventive strategies and much closer follow-up due to their elevated risk of subsequent adverse events.

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RESPIRATORY INSUFFICIENCY AFTER THE CORRECTION OF PECTUS EXCAVATUM: TWO CASE REPORTS KUTHAN KAVAKLI, SEZAI CUBUK, ERSIN SAPMAZ, HASAN CAYLAK, SEDAT GURKOK, ORHAN YUCEL, HAKAN ISIK, ALPER GOZUBUYUK, ONUR GENC Gulhane Military Medical Academy (GMMA), Ankara, Turkey Introduction Although various techniques have been described for correction of pectus deformity up till now, some modications of Rawitchs technique have been widely accepted. This technique involves subperichondrial excision of the overgrown costal cartilages, remodeling of the sternum and stabilization of the anterior chest wall. Herein we aimed to present these two morbidities which were the respiratory insufciencies, occurred after surgical repair of pectus deformities. Results Case One: A 21-year-old man was admitted to our department for the correction of his pectus excavatum deformity. The total resection of deformed costal cartilages including 3 to 7 costal cartilages bilaterally and anterior wedge osteotomy was performed. The correction and the stabilization of the sternum achieved with titanium plaque anteriorly. We inserted a chest tube in the right hemithorax because the leseration of mediastinal pleura then we opened the mediastinal pleura completely for the drainage of mediastinal bleeding. After 18 hours from the operation, respiratory insufciency occurred and he was entubated for mechanical ventilation. Two days after he extubated successfully and discharged on 10th postoperative day. Case Two: A 20-yearold man was admitted to our department for the correction of his pectus excavatum deformity. The same operation was performed and again we inserted chest tube in the right hemithorax intraoperatively because the leseration of mediastinal pleura then we opened the mediastinal pleura completely for the drainage of mediastinal bleeding. He did not tolerate the extubation postoperatively and he reentubated for mechanical ventilation. After seven days he extubated successfully and discharged on the 15th postoperative day. Conclusion Anterior stabilization of the sternum with our technique is a safe procedure. According to our experience, we should correct pectus deformities as possible as with Decreased Invasive Open Repair for adult patients. However if we extensively resect the deformed cartilages we should not open the mediastinal pleura completely.

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AN UNUSUAL CAUSE OF RESPIRATORY DISTRESS AND HEMOPTYSIS: LIVE LEECH IN THE LARYNX MOHAMMAD HOSSEIN RAHIMI-RAD1, REZA SAMAREE2 1 Department of Respiratory Medicine, and 2Department of Otolaryngology, Urmia University of Medical Sciences, Urmia, Iran The presence of a leech in the larynx gives rise to hemoptysis, airway obstruction, and a change in the voice. A foreign body, such as a leech, in the respiratory tract is an emergency and requires immediate attention because the ensuing airway obstruction may cause hypoxia and death. A 73-year-old male farmer patient was referred to our hospital with complaint of hemoptysis, dyspnea, dysphagia, and relapsing hoarseness for three weeks. In physical examination he had respiratory distress with hoarseness and stridor. Plain chest and larynx x-rays were normal. In transnasal broptic bronchoscopy, we found a dark brown leaf like material in larynx (gure 1). With inserting down FOB, the foreign body changed its shape become similar to worm (gure 2). Vocal cords were normal and a leech attached to arytenoid. Try for grasping of leech was unsuccessful. Under general anesthesia 4 ml lidocaine 2% injected to leech. After 5 minutes it became accid and removed. The patient experienced relief from breathlessness and started speaking normally After removing leech, the patient remembered that he had ingested spring water three weeks earlier, 3 days later he found recurrent attacks of hemoptysis, vomiting and hoarseness and respiratory distress. The patient had an uneventful postoperative period and was discharged a day later.

ISOLATED PULMONARY ZYGOMYCOSIS IN AN APPARENTLY NORMAL HOST: A CASE REPORT MOHAMMAD HOSSEIN RAHIMI-RAD Department of Respiratory Medicine, Urmia University of Medical Sciences, Urmia, Iran Zygomycosis is a rare fungal disease commonly affecting individuals with diabetes mellitus, hematological malignancy, and immune deciency. Isolated pulmonary zygomycosis is extremely rare. This article reports a case of isolated pulmonary zygomycosis that presented as a solitary cavity inltrate in a patient with no underlying risk factors. Presenting Case A 68 years old man came to our clinic in Urmia, Iran with chronic cough, anorexia and weight loss. He was a 40 pack-year smoker. He had no history of diabetes mellitus, tuberculosis, malignancy and corticosteroid or immunosuppressive treatment. Chest X-ray showed a homogeneous opacication in right upper lobe. Computed tomography-guided transthoracic needle biopsy of the lesion was performed and histological examination of the material demonstrated pulmonary zygomycosis. Control chest X-ray and CT scan revealed cavitation with crescent sign that change with position change. The Patient previous chest X-ray (6 months earlier) was normal. Three sputum samples were negative for acid fast bacilli. Blood glucose, CBC and ESR were normal. Conclusion Pulmonary zygomycosis rarely occur in apparently normal person and without previous pulmonary cavity.

Figure 1

Figure 2

Figures 1 and 2. Leech in larynx. Discussion Leeches are blood-sucking hermophroditic parasites that vary in color and range in length from a few millimeters to half a meter; they are leaf-like (gure 1) or cylindrical (gure 2) in shape, depending on the contraction of their bodies. Removal of a leech requires special care and the utmost gentleness because it attaches strongly with its suckers. This should be performed with great caution in hypopharyngeal or laryngeal manifestations to avoid mucosal edema, followed by possible dyspnea. Traction in this case may lead to arythenoid dislocation. Because of its soft and slippery body surface, which ruptures easily, it is difcult to hold a leech with force. Various anticoagulant agents are known to be injected by a leech and this may lead to bleeding and suffocation. A high index of suspicion of leeches as a cause of acute onset of respiratory distress associated with hemoptysis should be considered and early intervention to remove it is emphasized.

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MULTIPLE HYDATID CYSTS IN MULTIPLE ORGANS IN BOTH HUSBAND AND HIS WIFE WITH GOOD RESPONSE TO ALBENDAZOLE MOHAMMAD HOSSEIN RAHIMI-RAD Department of Respiratory Medicine, Urmia University of Medical Sciences, Urmia, Iran Introduction Hydatid disease is a zoonotic infection caused by larval stage of Echinococcosis granulosus. It is endemic in Iran. It is rarely reported in familiar form with similar imaging nding and good response to albendazole. Presenting Cases A 64 years old woman came to our clinic with chronic cough. She had never smoked. Chest X-ray showed a right paratracheal mass and a nodule in left lower lobe. Fiberoptic bronchoscopy was normal. Computerized tomographic scan (CT-scan) revealed multiple lungs and liver hydatic cysts. IgG echinoccos antibody test was strongly positive. Her husband (65 years old man a farmer) when heard that his wife disease is has an infectious etiology, began to ask us to order a chest X-ray for him because he had been worried about having similar disease. His chest X-Ray showed multiple bilateral nodules. He was 45 pack-year smoker. Fiberoptic bronchoscopy was normal. CT-scan revealed multiple pulmonary, liver and bilateral kidney hydatid cysts. We began treatment with albendazole 400 mg twice daily for both of them. At present after one year, control X-rays and ultrasonographic examinations show that cysts become smaller or some disappeared in both of them. Conclusion Hydatic cyst may be in a family with similar manifestation. Hydatic cyst responds well to albendazole treatment.

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THE AIRFLOW OBSTRUCTION IN PATIENTS WITH BRONCHIECTASIS YOUNG-MIN LEE Pulmonary Division of Internal Medicine, Busan Paik Hospital, Inje University, Busanjin-ku, Busan, South Korea Introduction Bronchiectasis is characterized by mild to moderate airow obstruction (AO) that tends to worsen over time. There are a variety of different pathogenesis involved in bronchiectasis. The purpose of this study was to dene the characteristics of the airow obstruction in bronchiectasis detected by chest CT. Methods A retrospective study of all patients who were diagnosed with bronchiectasis (20062008) was conducted at the Busan Paik Hospital, Inje University, in Busan. Tbc destroyed lung patients were excluded. Data regarding age, sex, sputum and bronchial washing Gram stain and cultures, spirometry, chest CT was obtained. Results 99 (42 men and 57 women) bronchiectasis patients (mean age 59.6 6.3 years) were studied. Spirometry showed FEV1/FVC of 63.2% 11.43 (range 30.3290.62), FEV1% pred 66.8 10.56 (range 30.35118.25). Airow obstruction was detected in 59/99 patients (59.5%): mild obstruction: 33/59 (56%), moderate obstruction: 13/59 (22%), severe obstruction: 13/59 (22%). Severe obstruction cases involved the diffuse extents more than 3 lobes 10/13 (77%). 27/59 (45%) of patients with airow obstruction were never smokers. 45/59 (76%) of patients with airow obstruction showed diffuse or multifocal bronchiolitis obliterans ndings in chest CT. Bronchial asthma was diagnosed in 17/59 (29%) of patients with airow obstruction. The most frequent potential pathogenic microorganisms were P. aeruginosa 34%, K. pneumonia 9.4%. In patients colonized with P. aeruginosa, airow obstruction was found in 15/18 cases (83%): the severe extents of bronchiectasis more than 3 lobes were 11/18 cases (61%). Conclusion In patients with bronchiectasis, airow obstruction is common and often combined bronchiolitis obliterans in chest CT. Bronchiectasis with P. aeruginosa colonization involves the severe extents more than 3 lobes and is often combined with airow obstruction.

QUALITY CARE OF PATIENTS ON NON-INVASIVE POSITIVE PRESSURE VENTILATION (NIPPV) HENRY POON CHUNG LEUNG, YUEN YEE CHAN, YUK YIN CHONG, SHU WAH NG, KIT CHING TSE Respiratory Ward 6A, Block S, 130 Hip Wo Street, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong Introduction NIPPV is a supportive therapy used to maintain adequate oxygenation and ventilation in patients with respiratory failure. It can avoid complications of endotracheal intubation, reduce infection risk, maximize quality of life and prolong survival. As NIPPV is widely used in our hospital, a self-initiative, promotion programs have been implemented since 2007 to enhance the safety and quality of care for patients on NIPPV. Methods Objectives (1) Enhance quality of care for patients on NIPPV; (2) Establish a mechanism in place to ensure quality care of it. Service review Our practice on care of patient on NIPPV was reviewed against the updated guideline. There are few areas identied for improvement as below. Guideline The guideline were revised and updated with reference to corporate guideline and best available evidence e.g. from BTS. Patient registration All patients on NIPPV would be registered in a respiratory ward to facilitate communication and comprehensive management. Logistic management All NIPPV machine are centralized in a respiratory ward for storage, maintenance, distribution, utility trend monitoring and terminal disinfection in order to maintain a safe and effective utilization. Competence enhancement There are seven lessons conducted since 2007 and one to two hour practicum with direct coaching has been provided for more than 100 colleagues in M&G department. Re-demonstration or quiz is required for candidates to test their competence. Quality assurance A practical guideline is established and accessible in units of Medicine & Geriatrics. We have phone and out-reach consultation services provided for prompt and continuous quality assurance. Video demonstration of setting and operation of the NIPPV machine is accessible in hospital webpage. Results Quality care for patients on NIPPV has been promoted, a mechanism is in place to ensure the safe and effective care. Nearly all (98%) candidates are satised with the training programs. For the course in advanced level, colleagues knowledge was signicantly improved after attending the course (p-value < 0.001). Conclusion The promotion provides a mechanism in place for quality assurance for caring patients on NIPPV. Competence of colleagues to care patients on NIPPV has been improved. More services outcomes remain to be explored such as compliance rate, complication prevention and hospital length of stay.

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END OF LIFE CARE IN MALIGNANT DISEASE: A CASE DISCUSSION WITH PULMONARY FELLOWS-IN-TRAINING OF THE PHILIPPINES SAMUEL SUNARSO, ISSER SUGAY, CHRISTINE AGATHA UNTALAN, PATRICK GERARD MORAL Center for Respiratory Medicine, UST Hospital, Espana, Manila, Philippines Introduction Physical and emotional pains are major burdens in patients with advanced lung cancer. While we often encounter these patients, as clinicians of pulmonary medicine we give different medications to alleviate the dyspnea and pain experienced by the patient. In line with this, it is not always easy to discuss to the patient and their relatives about advance directives (i.e. do not resuscitate). The objective of the study was to learn how pulmonologists manage patient with end of life malignant disease. Methods A conference for pulmonary fellows-in-training was held in our institution last February 5, 2009, regarding end of life care in patients with malignant disease. Keypads were distributed to the attendees at the start of the conference. During the forum, questions regarding approach to dyspnea, pain and discussion of advance directives and withdrawal of life support were projected on the screen. The respondents were given ample amount of time (30 seconds) to choose from four alternatives. The results and percentages were shown after each question. Results There were 54 attendees during the conference, however there were only 31 keypads available during the conference which were distributed to the delegates from the nine other training institutions. The results showed that in managing dyspnea, pharmacologic therapy was only used sometimes by the majority and that beta2-agonists were the main drugs used followed by opiates. In managing pain aside from NSAIDs, majority answered opiates followed by non-opiate relievers. With regards to conducting multidisciplinary meetings with the patient and relatives to discuss advanced directives, majority answered rarely. Moreover, majority have never reported to the Bioethics committee whenever a difculty in arriving at a decision is encountered. Conclusion Despite encountering many patients with malignant terminal disease, pulmonary fellows-in-training underutilize opiates in the management of dyspnea. However, these are their rst-line management for pain control after NSAIDs. In both symptoms, use of non-pharmacologic therapy may be encouraged. In these cases, most of the fellows are condent in discussing advance directives/DNR and withdrawal of life-support with the patient or their families. And withdrawal of life-support is usually done by the family.

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ENHANCEMENT PROGRAM ON CARING PATIENTS WITH UNDERWATER SEALED CHEST DRAINAGE MING WAH CHOI, SHU WAH NG, HENRY POON CHUNG LEUNG, KA MAN POON, KIT CHING TSE Respiratory Ward 6A, Block S, 130 Hip Wo Street, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong Introduction Chest drain (CD) is used to remove uid or air from pleural space to promote lung expansion. We yearly have 160 to 200 patients with CD in our respiratory ward. There are different types of patients who need CD such as pneumothorax, pleural effusion and empyema. We yearly had 153.75 pneumothorax cases that might need CD in our hospital. Their average length of stay was 5.02. Certain incidences related to patients care with CD such as dislodgement, kinking and loosening CD connection may potentially cause harm and increase hospital stay. As a self-initiative for patient safety and quality, we reviewed and identied areas for improvement and good practices for consolidation in caring patients with CD in hospital. Methods The cycle of quality improvement is based on describing, measuring, taking action and evaluation. Describing: A working group of the improvement program was established in April 2008 to steer audit, identify problems, analyze and recommend solutions. Measuring: An audit was conducted to review the real practices against the standard criteria from August 2009 to February 2010 after the implementation of the enhancement program. Convenience sampling method was used. Total 26 cases were audited. Taking action: There are actions taken for the identied areas including: (1) updating guideline on care of patient with CD, (2) conducting hospital-wide training courses, (3) establishing mechanism of caring patient with CD in hospital, (4) modifying monitoring tools e.g. CD observation chart and dressing method, (5) developing service for ambulatory cases, (6) enhancement on patient education e.g. leaet. (7) conducting post-implementation audit. Evaluation: The quality of caring patients with CD is monitored by Duty-In-Charge. Regular audit is conducted to reviewed the practices and identify areas for further improvement. Results A quality improvement program for caring patients with CD has been implemented. There were actions taken regarding to the identied areas for improvement such as updated guideline with evidence based, hospital-wide training with multimedia training package. The compliance rate on caring patients with CD has been improved from 85.16% to 90.05%. Conclusion Care of patients with CD has been improved. A number of actions have been taken for quality improvement. The service of care of patients with CD will be extended not only in the hospital but also for ambulatory care.

PROMOTE SAFE AND EFFECTIVE MANAGEMENT FOR CARING PATIENTS WITH TRACHEOTOMY TUBE (TT) SAI HONG CHAN, MING WAH CHOI, PUI FAN CHAN, SHU WAH NG, CHUNG LEUNG POON Respiratory Ward 6A, Block S, 130 Hip Wo Street, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong Introduction Tracheotomy is a surgical procedure to create an opening through the neck into the trachea for bypassing acute upper airway obstruction, preventing aspiration of bronchial secretions, prolonging and assisting ventilation. Tracheostomy care is a high risk procedure which require integration of specialty knowledge, nurses with specialty training and special area with adequate equipment provided, patients with tracheotomy might stay for few months in hospital. Thus, a self-initiated enhancement program on caring clients with tracheotomy has been implemented to enhance safety and quality of the services. Methods Guideline Review and Update: The care of clients with Tracheotomy Tube (TT) was reviewed with reference to best available evidence and corporate guideline. Practice on caring client with TT was reviewed against the operational guideline. There are few areas identied for improvement such as clinical pathway, explanation, patients communication problem, empowerment and in-service training. Clinical Pathway: The journey of patients who need TT during the peri-operative period to discharge was indicated with estimated timeframe. Thus, client and carer could recognize what, why, how and where the thing may happen to them. Their needs would be assessed in a holistic view with physical, psychosocial, spiritual and nancial aspects. Multi-disciplinary Team Approach: A specialty nurse is assigned to be case manger. Multi-disciplinary approach would be used to care of clients with TT. Empowerment: A structural training and individualized plan would be given to patient and carer. Their competence and condence were built after training and they could be able to manage the care by themselves with our assistance in the community. Results A clinical pathway for tracheotomy care was established in place to ensure the quality of care of it. Patients, carers and staff nearly all expressed they were satised with the program provided. The knowledge of staff on caring patients with TT was signicantly improved (p-value < 0.001). Conclusion A clinical pathway for tracheotomy care is established enhance the quality of tracheotomy care. The knowledge of staff on caring patient with TT was signicantly improved after attending the training program. More service outcomes would remain to be explored to indicate the effectiveness of the program such as hospital length of stay, complication and re-admission rate.

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ANEURYSMAL BONE CYST OF THE RIB (A CASE) AYSE BAHADIR, GONENC ORTAKOYLU, FIGEN ALKAN, EMEL CAGLAR, LEVENT CANSEVER, MEHMET ALI BEDIRHAN Yedikule Chest Hospital-Istanbul, Turkey Introduction Primary neoplasms of the ribs are uncommon and malignant tumours are signicantly more common than benign tumours in this location. An aneurysmal bone cyst is an expansile osteolytic lesion with a thin wall, containing blood-lled cystic cavities. The condition is a rare benign, progressive bone tumour. The aetiology and natural history are unknown. Methods 40-year-old woman presented with a few months history of pain on the right side of her chest. There was a history of trauma to the her chest in childhood. Except for mild tenderness over the area, the physical ndings and laboratory values were all within normal limits. Chest radiography and CT of thorax showed on aneurysmal bone cyst of the right sixth rib. Results The mass and the adjacent segment of the sixth rib was resected en bloc. Recovery was uneventful and at the follow up two months later the patient was getting well. The pathological diagnosis was solitaire bone cyst. Conclusion Because of the rarity of this condition, a case with aneurysmal bone cyst of the rib is presented.

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THE ASSOCIATION OF LUNG FUNCTION AND METABOLIC SYNDROME COMPONENTS IN A CROSS SECTIONAL STUDY OF MALAYSIAN POPULATION JUSTIN GNANOU, BRINNELL CASZO, WAN HANIZA WAN MOHAMAD, FADHLINA ABD MAJID, HAPIZAH NAWAWI, KHALID YUSOFF, TENGKU ISMAIL, CRISPS INVESTIGATORS Faculty of Medicine, Universiti Teknologi MARA, Shah Alam, Malaysia, Malaysia Introduction Chronic Obstructive Pulmonary Disease (COPD) and metabolic syndrome (MS) are conditions associated with systemic inammation. Patients with COPD or MS have an increased risk of cardiovascular diseases but the association between the two conditions has not been clearly shown. The objective was to study the association between lung function and MS components. Methods 2400 adult subjects were included in this cross-sectional study. The subjects were divided into 2 groups based on the spirometry results subjects with evidence of airow obstruction (FEV1/FVC < 70%) and normal lung function. The subjects anthropometry and fasting blood samples were taken. Results There were 2305 patients (96.04%) with normal, and 95 (3.96%) with an obstructive pattern on spirometry. Patients with an obstructive pattern were signicantly older (p < 0.000) more frequently male (p < 0.001) and rural dwellers (p < 0.000) than those with a normal pattern. The mean BMI (p < 0.014) and systolic blood pressure (p < 0.001) were higher in the obstructive group. Hyperglycemia was more prevalent in the obstructive pattern group (p < 0.03) but there was no signicant difference in the prevalence of hypertension, low HDL and high triglyceride levels between the 2 groups. Conclusion The subjects with obstructive lung function were more likely to be obese, have higher systolic blood pressure and hyperglycaemia compared to those with normal lung function. The presence of these traits associated with airow obstruction on spirometry may represent a common systemic inammatory state. This study is supported by MOSTI (Ministry of Science, Technology and Innovation) grant.

A GIANT TYPE I BULLAE MANIFESTING AS LEFT PULMONARY ARTERIA HYPOPLASIA KUTHAN KAVAKLI, CANTURK TASCI, HASAN CAYLAK, ERSIN SAPMAZ, DENIZ DOGAN, ORHAN YUCEL, ALPER GOZUBUYUK, SEDAT GURKOK, ONUR GENC GMMA, Turkey Introduction The giant bullae is dened as the bullae formation of lung tissue which is larger than one half of a hemithorax. The presenting symptom is usually progressive dyspnea but it can be manifesting as various clinical course. Results A 34-year-old man admitted to Chest Disease Department with the complaint of progressive dyspnea and chest pain last 10 months. The left sided hyperination was discovered on chest X-ray. Pulmonary function test revealed restrictive pattern (FEV1/FVC: 76%, FVC: 74% and FEV1: 67%). Thorax CT revealed bullous left upper lobe, parsial atelectasia due to compression of giant bullae and a hypoplastic left pulmonary artery. The perfusion mismatching of left upper lobe was determined in V/Q scintigraphy. There was no endobronchial lesion in beroptic bronchoscopic examination. He was referred to our clinic for surgical treatment of prediagnosis of infantile lobar emphysema or Swyer-James-Macleod syndrome. He underwent left thoracotomy and the giant type I bullae was resected. There were multiple left sided patch inltrations on chest X-ray on the rst postoperative day which was compatible with re-expansion pulmonary edema. The chest X-ray was normal on the seventh postoperative day and subsequently the patient was discharged in stable condition. The pulmonary function test revealed approximately 50% improvement after two months (FEV1/FVC: 97%, FVC: 111% and FEV1: 104%). Conclusion When there is a giant bulla in one hemithorax, the differential diagnosis can be challenging due to different presentation of the patients. If a giant bullae with normal lung parenchyma resected it will result in expansion of the compressed lung parenchyma and pulmonary function will demonstrate signicant improvement.

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EFFECT OF SPECIAL MILITARY TRAINING ON MAXIMAL OXYGEN VOLUME (VO2 MAX) AND LUNG FUNCTION AMONG MARINER SPECIAL FORCES MEMBER AGUNG KRISTIYONO, LAKSMI WULANDARI, SLAMET HARIADI, YUSUF WIBISONO Jl. Ketintang Wiyata 02/25, Surabaya, Indonesia Introduction Maximal oxygen volume (VO2 max) increased linearly with work load up to maximal level and then attening. Consistent training can increase cardiorespiratory function described as an increase in VO2 max and lung function. Other factors that inuence VO2 max include hereditary, age, gender, intensity and severity of training. We studied the effect of special military training on VO2 max and lung function among Mariner Special Force member. Methods This quasi experimental pre-post test design study recruited 42 members of Indonesian Mariner Special Force. All of the subjects undergone baseline demographic measurement (rank, age, weight, height, body mass index (BMI), blood pressure, and pulse rate). VO2 max and lung function test were done before and after 6 months of regular training. Results There were improvements in VO2 max and lung function test parameter after 6 months regular training. VO2 max increased signicantly from 48.85 mL/min/kgBW to 60.03 mL/min/kgBW (p < 0.001). VC, FVC, and FEV1 also improved signicantly [3904.04 mL vs. 4091.20 mL (p < 0.001); 3837.14 mL vs. 3958.00 mL (p < 0.001); 3276.90 mL/sec vs. 3361.42 mL/sec (p < 0.001) respectively]. Conclusion Regular training for 6 months such as special military training for mariner can signicantly improve cardiorespiratory function reected by signicant increase in VO2 max and lung function test parameters.

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ATYPIC FLAIL CHEST OCCURRENCE DUE TO A GIANT CAVITY IN THE CHEST WALL: A CASE REPORT KUTHAN KAVAKLI, ORHAN YUCEL, SEDAT GURKOK, ONUR GENC, HASAN CAYLAK, ERSIN SAPMAZ, ALPER GOZUBUYUK, SEZAI CUBUK GMMA, Turkey Introduction Flail chest is a clinical course which occurs when there is a paradoxally movement of an instability of a chest wall segment. Herein, we presented a case who had no paradoxally movement of a chest wall segment but he had ail chest pathophysiology between left thoracic cavity and giant cavity in the chest wall which was occurred by blast injury of bullet. Results A 20-year-old man has admitted with bullet injury from left chest. There was a giant cavity in the thoracic wall, combined with thoracic cavity, on thorax computerized tomography (Figure 1). There was not any signicant contusion. However mechanical ventilation has been performed for seven days and then he was successfully extubated. In our case, there was a pendelluft mechanism between left thoracic cavity and giant cavity in the chest wall which was occurred by blast injury of a bullet unlike the presence of paradoxal movement of a chest wall segment (Figure 2). The second thorax computerized tomography revealed obliteration of the cavity in the chest wall and parenchymal healing (Figure 3).

THE SKELETAL MISFORTUNE: KLIPPEL-FEIL SYNDROME WITH POTTS DISEASE RHEA LOUELA JUSI, FERNANDO AYUYAO, TERESITA DE GUIA Division of Pulmonary and Critical Care Medicine, Philippine Heart Center, Philippines Introduction The objective of this report is to present a case of a 30 year-old male with cervicothoracic vertebral deformity and discuss its radiographic and ancillary evaluation which lead to the diagnosis of Klippel-Feil syndrome with Potts disease. Results This is a case of J.D. 30 year-old male, who has kyphosis with chief complaint of dyspnea. On examination, he has low hairline, short webbed neck, limited neck motion, with sensorineural hearing loss. ABG showed acute on top of chronic respiratory acidosis. Chest x-ray showed PTB both upper lobes with narrowed upper intercostal spaces. Cervical x-ray showed fusion of the posterior cervical vertebrae with blocked body of C5C6, and narrowing of C4C5 disc space likely congenital in origin. Cervical MRI showed exaggerated kyphosis of the upper thoracic spine with cobbs angle 70 degrees with blocked C5C6 vertebra. Chest CT scan showed Gibbus deformity, synostosis in the upper thoracic spine, pleuroparenchymal brosis, volume loss, tubular and cystic brochiectasis, blebs, bullae and pleural thickening in right upper and middle lobe. Pulmonary function test revealed mixed restrictive and obstructive lung defect. Considering his short webbed neck, limited neck motion and low hairline, coupled with blocked cervical fusion and gibbus on chest x-ray and MRI, the diagnosis of both Potts disease with concomitant congenital cervical vertebral bone abnormality is conrmed. Conclusion This patient was diagnosed to have Klippel-Feil syndrome and Potts disease. The collective evidence points to an extraordinary juxtaposition of events that of an acquired deformity on top of a congenital abnormality. It is a combination so rare that it has never been reported in our country, and has only been documented once in literature in the exhumation of Cardinal Carlo de Medici. We can only speculate who among our countless patients with spinal tuberculosis actually has concomitant Klippel-Feil syndrome, or congenital spinal fusion masquerading as Potts disease.

Figure 1

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Conclusion We should consider in mind a ail chest pathophysiology when there is a giant cavity in the chest wall which was occurred by blast injury of bullet and had a combination with thoracic cavity.

A COMMON OCCURRENCE OF A RARE DISEASE: PULMONARY ARTERY SARCOMA AT PHILIPPINE HEART CENTER A CASE SERIES MYLA CASTILLO, TERESITA DE GUIA, MARIA PAZ MATEO, CHRISTOPHER CORTES, POLLY DOMINGO Division of Pulmonary and Critical Care Medicine, Philippine Heart Center, Quezon City, Philippines Introduction Objectives of this study are to present 3 separate cases of Pulmonary Artery Sarcoma and review the literature on this rare disease, emphasizing on clinical presentation, diagnostic modalities and management. 2007 A 56-year old female presenting with progressive difculty of breathing and pulmonary hypertension. She was managed as pulmonary thromboembolism. TEE and CTPA showed a intraluminal mass, probably sarcoma versus myxoma in the main pulmonary artery segment extending to both proximal pulmonary artery. Surgical intervention was not done. Histopathologic examination was executed post mortem. 2008 BEJ, 29-year old female presented with loss of consciousness. Cranial CT scan was normal. TEE revealed echogenic density at the main pulmonary artery with extension in the posterior valve leaet causing obstructive and hemodynamic effect. Initial considerations were pulmonary embolism vs sarcoma. CT angiogram revealed large lling defect at the pulmonary artery extending to both main pulmonary artery totally occluding the left. Patient underwent the rst successful Pulmonary Thrombo-Endarterectomy. Histopathologic ndings revealed PLEIMORPHIC PULMONARY ARTERY SARCOMA. She was apparently well until tumor recurrence was detected after 6 months. 2009 MEA, 38 year old female who presented with progressive shortness of breath. Diagnosed to have CPTD and included in an International study and was considered to be treatment failure. Despite adequate treatment for embolism, there was persistence of shortness of breath. D-dimer, Venous duplex scan and work up for hypercoagulable disease were normal. 2D Echocardiography showed mass on RVOT and Right pulmonary artery. Patient underwent the second successful Pulmonary Thrombo-Endarterectomy with excision of Pulmonary artery and RVOT mass in Philippine Heart Center and in the Philippines. She underwent leukapharesis and immunotherapy. She is currently asymptomatic on her 9th month upon diagnosis. Conclusion Pulmonary Artery Sarcoma are highly aggressive and locally invasive tumors, with short life expectancy unless treated. Literature advocates radical surgical resection as the sole chance for prolonged survival even if cure is unlikely. The median length of survival of patients without surgery is only 1.5 months while resection could improve survival from 10 months to 5 years.

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LARGE MULTIPLE PULMONARY ARTERIOVENOUS FISTULA WITH MULTIPLE CEREBRAL ABSCESSES A CASE REPORT SITTI NURISYAH, WINARIANIA K, SOEDARSONO Dr. Soetomo General Hospital Airlangga University, Surabaya, East Java, Indonesia Introduction Pulmonary arteriovenous malformation (PAVM) is an uncommon congenital anomaly. PAVM is a direct connection between artery and vein in the pulmonary circulation. PAVM occurs in variety of clinical situations, such as cyanosis, dyspnea, and digital clubbing. Patients with PAVM are having an increasing risk of cerebral abscess. Methods We report the case of a 14 years-old, male patient, who is since 8 years ago had cyanosis which is difcult to explain using common diagnostic tests. His clinical examination only mention sign and symptom like chest pain, cyanosis, clubbing ngers, and focal seizures. Blood gas analysis demonstrated alkalosis respiratory with severe hypoxemia and the initial tests do not detect any cardiac abnormalities. The routine chest radiograph revealed a sharply dened lobulated soft tissue mass of uniform density in the right upper hemithorax. He underwent a cerebral CT Scan and was diagnosed to have a multiple cerebral abscesses. Results The diagnosis was established on the basis of contrast-enhanced computed tomography angiography with three-dimensional images (3D-CT), and the results revealed as right pulmonary artery caliber 26 mm in size, large multiple pulmonary arteriovenous stula, small shunting between the right pulmonary artery and proximal descending aorta, no mass in the right lung, and hepatoportal shunt liver. Conclusion Pulmonary arteriovenous stula is not easily diagnosed with common tests, due to its rarity and its unspecic ndings on routine examinations. However, this diagnostic hypothesis should always be considered when examining children with cyanosis, in whom the initial test do not detect cardiac abnormalities. Contrast-enhanced 3D-CT appears to be a reliable noninvasive tools for pretherapy evaluation of PAVM.

PULMONARY SEQUESTRATION IN A 22 YEAR OLD FEMALE: A CASE REPORT BUDI YANTI, LAKSMI WULANDARI, SLAMET HARIADI, YUSUF WIBISONO Dr. Soetomo General Hospital Airlangga University, Surabaya, East Java, Indonesia Introduction Pulmonary sequestration is a cystic or solid mass composed of nonfunctioning primitive tissue that does not communicate with the tracheobronchial tree and has anomalous systemic blood supply. It is a type of congenital thoracic malformation. It may present as a lung infection on physical examination and chest imaging and might be misdiagnosed as abscess or uidopneumothorax. The 2 forms of pulmonary sequestration are intrapulmonary, which is surrounded by normal lung tissue, and extrapulmonary, which has its own pleural investment. Intrapulmonary sequestrations are the most common form, and 60% of these are found in the posterior basal segment of the left lower lobe. Intrapulmonary sequestration occurs within the visceral pleura of normal lung tissue. Usually, no communication with the tracheobronchial tree occurs. The most common location is in the posterior basal segment, and nearly two thirds of pulmonary sequestrations appear in the left lung. Results A 22 year old female presented with dyspnea and chronic cough since the last 1 month. She expectorates yellow brownish sputum, sometimes with blood streak. Chest X-ray showed a giant cavity with air uid level in the left lung. Thorax CT scan conrmed the presence of the giant cavity, sized 11.7 10.1 19.0 cm in superior and inferior lobes of the left lung with surrounding brosis, excluding an encapsulated pleural effusion suspected before. Bronchoalveolar lavage revealed positive acid fast bacilli (AFB +). She underwent explorative thoracotomy. There was bullae sized 8.0 8.0 8.0 cm stuck to lung parenchyma and visceral pleura which contained greenish liquid materials. Pathologic examination revealed cystic mass covered by respiratory epithelium connected with bronchus-like structure, inltrated with chronic inammatory cells. The clinical picture is consistent with intrapulmonary sequestration. Inferior lobectomy was subsequently performed, and antituberculosis drug (rst category) was given. Her condition improved and currently on well condition. Conclusion We reported a rare case of pulmonary sequestration infected with tuberculosis. The case was successfully managed by inferior lobectomy and antituberculosis treatment.

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OUTCOME OF PREGNANT PATIENTS WITH PULMONARY HYPERTENSION IN A TERTIARY GOVERNMENT HOSPITAL AVEN-KERR UBALDE, ABUNDIO BALGOS Section of Pulmonary Medicine, UP Philippine General Hospital, Taft Avenue, Manila, Philippines Introduction Pulmonary Hypertension is not well-tolerated in pregnancy. Symptoms may include fatigue, dyspnea, chest pain, cough, or syncope. Decompensation typically occurs in the second trimester. The normal physiologic and hemodynamic changes of pregnancy and labor put signicant burden on the cardio-pulmonary system, especially in the presence of increased pulmonary vascular resistance. Successful deliveries by vaginal and caesarean section have been described. But can still have signicant morbidity and mortality. Methods Pregnant patients with evidence suggestive of pulmonary hypertension were included. A review of their clinical prole was done. Patients were monitored and observed during pregnancy until delivery and hospital discharge or death. Results 4 cases were referred in 1 year period, ranging from 2732 years old. Predominant symptom was exertional dyspnea which started before pregnancy. 1 patient had hemoptysis which resolved post-partum. Other complaints were cough, throat irritation, hoarseness, chest pain. Clinical suspicion was supported by 2D-Echo and Chest X-ray. No patients had right-heart catheterization. They were given a calcium channel blocker or a phosphodiesterase-5 inhibitor. O2 support was given via nasal cannula or face mask, and monitored by pulse oxymetry. 1 patient received anticoagulation with heparin daily which was later shifted to sc enoxaparin. 1 patient had ventricular septal defect with SLE. Another had PTB with bronchiectasis. 2 patients had limited funds to complete work-ups to determine the cause. They were admitted within 4 weeks before delivery; 2 of which delivered within 24 hours of admission. 1 reached term pregnancy, while the rest delivered at 35th36th wk AOG. 3 patients delivered vaginally under epidural anesthesia, 2 by way of assisted outlet forceps extraction; 2 were later discharged, while 1 patient who delivered via forceps extraction died 5 days post-partum. 1 patient delivered by caesarean section under general anesthesia died 2 days post-partum. All babies survived the delivery. All patients were monitored in an intensive care unit pre- and post-delivery. Conclusion Pulmonary hypertension remains to have a high mortality rate even after successful delivery of the fetus. Patients in the lower socioeconomic class are affected by limited resources to arrive at an appropriate diagnostic and therapeutic management.
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HEAT SHOCK PROTEIN 70 PROTECTS AGAINST BLEOMYCININDUCED PULMONARY FIBROSIS IN MICE KEN-ICHIRO TANAKA, TOHRU MIZUSHIMA Kumamoto University, Kumamoto, Japan Introduction Idiopathic pulmonary brosis (IPF) is considered to involve a process of pulmonary injury (inammation), brosis (collagen deposition) and resulting pulmonary dysfunction. Myobroblasts and transforming growth factor (TGF)-1 have been suggested to play a major role in the pathology. In this study, we examined the effect of expression of heat shock protein 70 (HSP70) on bleomycin-induced pulmonary brosis in mice, a tentative animal model of IPF. Methods The severity of bleomycin-induced pulmonary injury, the inammatory response and brosis in mice was assessed by various methods. Lung mechanics were assessed by a computer-controlled ventilator. Results Bleomycin-induced pulmonary injury, inammatory response, brosis and dysfunction were ameliorated in transgenic mice expressing HSP70 compared to wild-type mice. The production of TGF-1 and expression of pro-inammatory cytokines were lower in the transgenic mice than in wild-type mice after the administration of bleomycin. In vitro, the suppression of HSP70 expression stimulated TGF-1-induced epithelial-mesenchymal transition (EMT)-like phenotypes of epithelial cells but did not affect the TGF-1dependent activation of broblasts. Orally administered geranylgeranylacetone (GGA), a clinically used drug with HSP-inducing activity, conferred protection against bleomycin-induced pulmonary injury, as well as against the inammatory response, brosis and dysfunction. Conclusion These results suggest that HSP70 plays a protective role against bleomycin-induced pulmonary injury, inammation, brosis and dysfunction through cytoprotective effects and by inhibiting the production of TGF-1, TGF-1-dependent EMT of epithelial cells and expression of proinammatory cytokines. Results suggest that HSP70-inducing drugs, such as GGA, could be therapeutically benecial in the treatment of IPF.

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PHARMACOLOGIC INHIBITION OF ACTIVIN RECEPTOR-LIKE KINASES-5 BY SB 431542 ATTENUATES BLEOMYCIN-INDUCED PULMONARY FIBROSIS RHUN YIAN KOH1, BRUCE D UHAL2, CHOOI LING LIM1, MAHA ABDULLAH3, SHARMILI VIDYADARAN3, COY CHOKE HO4, HENG FONG SEOW5 1 International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000 Kuala Lumpur, Malaysia, 2Department of Physiology and Biomedical Sciences, Michigan State University, 2201 Biomedical Physical Sciences, East Lansing, MI 48837, USA, 3Immunology Unit, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia, 4Research Ofce, 4-12A, Fortuna Court, 54, Jalan Awan Cina, Taman Yarl, 58200 Kuala Lumpur, Malaysia, and 5School of Graduate Studies, Zone 4, Off Jalan Stadium, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor Darul Ehsan, Malaysia Introduction Idiopathic pulmonary brosis (IPF) is a chronic pulmonary disease characterized by the formation of scar tissue in the lungs. Transforming growth factor-beta (TGF-) is an important cytokine involved in the pathogenesis of the disease. SB 431542, a small molecule which selectively binds to activin receptor-like kinase-5 (ALK-5), inhibits the expression of TGF-. In the recent study, the effect of SB 431542 on pulmonary brosis was determined. Methods The effect of SB 431542 on TGF--induced alpha-smooth muscle actin (-SMA) expression in lung broblast (IMR-90 cells) was determined by Western blot and Real-time PCR. IMR-90 cell proliferation was determined by growth curve assay. In the in vivo study, SB 431542 was given simultaneously with bleomycin on Day-0 to ICR mice in early-treatment regime. Bleomycin was given on Day-0, but treatment with SB 431542 was given on Day-5 and Day-10 for the delayed-treatment regime. The mice were sacriced on Day-14 and lungs were removed for various assays. Morphological changes in the lungs were observed and the collagen expression was determined by hydroxyproline quantitation. Results We have demonstrated that SB 431542 inhibited the TGF--induced -SMA expression in IMR-90 cells, at both protein and mRNA levels (p < 0.05). It was also shown that the compound reduced IMR-90 cell proliferation. Bleomycin treatment led to signicant morphological changes accompanied by upregulation of collagen expression in mice lungs. Both early and delayed treatments with SB 431542 prevented the histopathological alterations and collagen expression (p < 0.05). Conclusion These results suggest that ALK-5 inhibition by SB 431542 attenuates pulmonary brosis.

ACCURACY OF CLINICAL-RADIOLOGICAL DIAGNOSIS OF INTERSTITIAL PNEUMONIA BY PHYSICIANS WITH DIFFERENT LEVELS OF EXPERIENCE KENSUKE KATAOKA, HIROYUKI TANIGUCHI, YASUHIRO KONDOH, KIMINORI FUJIMOTO, MASANORI KITAICHI, MASASHI KONDO, NAOZUMI HASHIMOTO, TAKESHI JOHKOH Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan Introduction In clinical practice, many patients with idiopathic interstitial pneumonias do not visit institutions with expertise in the eld of interstitial lung disease, and primary pulmonary physicians should often make diagnosis and conduct medical treatment. Evaluate differences between less experienced and expert physicians skill in diagnosing idiopathic interstitial pneumonias (IIPs) before surgical lung biopsy. Methods Two expert pulmonologists, two nonexpert pulmonologists, two expert radiologists and two nonexpert radiologists reviewed 74 consecutive cases of suspected idiopathic interstitial pneumonia. Each participant was provided information in a sequential manner and was asked to record their diagnostic impression at each step (Table 1). At the nal step, the expert and nonexpert teams reached a consensus diagnosis and rated their level of condence separately. The accuracy of each diagnostic step in each team was evaluated by comparing the multidisciplinary diagnosis by The Tokai Study Group Conference for Diffuse Parenchymal Lung Disease.

Table 1.

Organization scheme of study

Results At each step, the accuracy of expert physicians was superior to that of nonexpert physicians (Table 2). At the nal step, the accuracy of diagnoses that the expert team reached with high condence was perfect. Conversely, the accuracy of diagnoses that the nonexpert team reached with low condence was very poor.

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MINIMUM SPO2 OR END SPO2 DURING 6MWT IN IPF: WHAT IS BETTER? AMRIT GOEL, ANURADHA AHUJA, RITESH SINGH, AMRIT GOEL, DEEPAK PABREJA, DEEPAK TALWAR 166, Shakti Khand, Inderapura, Ghaziabad, India Introduction Exercise SpO2 at the end of 6MWT is used frequently to assess severity in IPF Since end SpO2 is not the minimum saturation during 6MWT, we hypothesize that minimum SpO2 would more accurately reect functional capacity in IPF. Further we tried to nd out if minimum or end SpO2 during 6MWDT correlates with functional exercise capacity in IPF. Methods 71 patients with diagnosis of IPF were prospectively evaluated by 6MWT without supplemental oxygen (ATS guidelines) with continuous SpO2 analyzed (Motion resistant). Baseline SpO2 (SpO2baseline), minimum SpO2 (SpO2min), SpO2 at the end of the test (SpO2end), 6-minute walk distance, rate of perceived exertion (Borg Scale), lung functions (FVC% predicted, FEV1% predicted & FEV1/FVC, DLco & DLco% predicted) were recorded. Pearson correlation coefcient was used to analyze the relation between various parameters and signicant value was taken at p 0.05. Results SpO2baseline was 95.96 2.31% which was signicantly correlated with the 6MWD (p < 0.0001). SpO2min (81.34 8.23%) was signicantly less than the SpO2end (89.44 6.77%). Neither of these saturations or their difference with SpO2baseline was signicantly correlated with any of the lung functions or the 6MWD. SpO2end was signicantly correlated with RPE at the end of the test (r = 0.44; p < 0.0001). However, RPE signicantly correlated with fall in saturation from baseline to end (p = 0.001) also, time to maximum desaturation was signicantly correlated to both the SpO2min and SpO2end (p = 0.001 & p < 0.0001 respectively). Conclusion Neither minimum nor end SpO2 during 6MWT without supplemental oxygen, correlates with Functional exercise capacity in IPF. However their role in monitoring progress in IPF needs further studies.

Table 2. (n = 74)

Concordance rates between each step and gold standard []

Conclusion The accuracy of expert physicians is signicantly superior to that of nonexpert physicians in the eld of interstitial lung disease. Patients with suspected IIPs should be referred to centers with expert in this area to help clarify the diagnosis.

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THE UNUSUAL USUAL LUNG DISEASE FATIMA KATHRINA MAGPANTAY, TERESITA DE GUIA Division of Pulmonary and Critical Care Medicine, Philippine Heart Center, Quezon City, Philippines Introduction Objectives of this study is to present a case of a 44 year-old female with usual interstitial pneumonia and to review the literature on this rare disease entity, emphasizing on clinical presentation, diagnostic modalities and current treatment. Results We are presenting a case of A.S., a 44 year old female who presented with progressive dyspnea, dry cough and clubbing of ngers. On work up, patients chest X-RAY revealed pulmonary tuberculosis and pneumonia. Consideration at this time was pneumonia. However, patients symptoms did not improved despite treatment. Further work up done. Chest CT scan revealed interstitial pneumonia, ANA was negative, pulmonary function test revealed restrictive lung disease. Impression at this time was Interstitial lung disease. She was referred to Thoracovascular service for lung biopsy which is the gold standard. The histopathologic result showed usual interstitial pneumonia. Conclusion UIP is a chronic progressive form of lung disease with short life expectancy. Treatment of UIP is highly controversial and therapeutic options are limited and usually ineffectual. Corticosteroids or immunosuppressive agents were used in an attempt to ablate any inammatory component. But despite current treatment options median survival without lung transplant is 23 years. With single lung transplantation, the 5 year survival was 4060%. The current study supports the possibility of using systemic administration of mesenchymal stem cells for treatment of various brotic conditions, however efcacy appears to still require optimization.

PULMONARY SARCOIDOSIS WITH OTHER ORGAN INVOLVEMENT: A CASE REPORT LAKSMI WULANDARI, HANDRIYANI HANDRIYANI, JUSTINUS FRANS PALILINGAN, SLAMET HARIADI, YUSUF WIBISONO Pulmonology Department, Dr. Soetomo Teaching Hospital, Airlangga University School of Medicine, Surabaya, Indonesia Introduction Sarcoidosis is a systemic granulomatous disease of immunologic cause. Characteristically it is featured by non-caseating granulomas in various parts of the body, especially in the lung and the lymphoid system. We reported this very rare case which can be managed successfully by systemic corticosteroid. Results A 29 year old man presented to our hospital with chronic cough for 1 year. He had been previously diagnosed as having tuberculosis and had received 8 months anti-tuberculosis treatment without any clinical and radiologic improvement. Physical examination revealed several nodules on retroauricular and cervical area, also on right upper and lower arm. There was enlargement of the spleen (Schuffner I). Chest X-ray showed paratracheal and hillar lymph node enlargement and bilateral reticulogranular inltrates on both lung elds. Laboratory examination showed hyperuricemia and mild azotemia. Abdominal ultrasound revealed nonspecic splenomegaly. Lung function test showed severe restriction and obstruction. Biopsy on cervical and upper arm nodules showed non-caseating granuloma with epithelioid cells and lymphocyte inltration which consistent with sarcoidosis. Systemic corticosteroid was given immediately after diagnosis. After 2 months of steroid treatment there was some improvement in clinical, laboratory, radiology, and lung function evaluation. Serum angiotensin converting enzyme level decreased from 214 IU/L to 18 IU/L. Conclusion Pulmonary sarcoidosis is a rare case which may misdiagnosed as tuberculosis. The disease may involve several other organs such as lymph node, spleen, and kidney. Proper treatment with systemic corticosteroid successfully brings the disease into remission.

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A CASE OF LUNG INJURY RELATED TO MESALAMINE ENEMA TOSHIMICHI HORIUCHI, HANAOKA MASAYUKI, WADA HIROSUKE, USHIKI ATSUHITO, YAMAMOTO KAORI, GOMI EIICHI, ARAKURA NORIKAZU, KUBO KEISHI 1st Department of Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, Japan Introduction Mesalamine (5-aminosalicylic acid) is used in the treatment of inammatory bowel disease. Lung injury related to mesalamine has rarely been reported. Methods A 25-year-old woman with ulcerative colitis, developed dry cough and shortness of breath. She had taken mesalamine tablet and enema from 3 months ago. CT scans revealed bilateral pulmonary inltrates. Bronchoalveolar lavage uid showed increase of eosinophils. And there was no effect of antibiotics. Mesalamine enema-induced lymphocyte stimulating test was positive, but mesalamine tablet-induced was negative. Therefore the patient was diagnosed as eosinophilic pneumonia related to mesalamine enema. Results Her symptom improved after discontinuation of mesalamine (both tablet and enema) and administration of prednisolone 0.75 mg/kg/day two weeks. Later, although mesalamine tablet has resumed, lung injury was no recurrence. We considered this lung injury occurred due to some additives in mesalamine enema. Conclusion We considered this lung injury occurred due to some additives in mesalamine enema.

PROLONGED MECHANICAL VENTILATION AMONG CHILDREN WITH CONGENITAL HEART DISEASE UNDERGOING CARDIAC SURGERY: A RISK FACTORS ANALYSIS CHARINA LAGYAL, TERESITA DE GUIA, FERNANDO AYUYAO, MILAGROS BAUTISTA, NERISSA DE LEON Division of Pulmonary and Critical Care Medicine, Philippine Heart Center, Quezon City, Philippines Introduction Most children who undergo congenital heart surgery require postoperative mechanical ventilation (MV). Less than 50% of these patients require MV support for more than 3 days. It is lifesaving but involves serious complications and increases the cost of hospital care. Aim of this study is to determine the different risk factors for prolonged mechanical ventilation (PMV) among children with congenital heart diseases undergoing cardiac surgery. Methods A cohort study in pediatric patients who underwent cardiac surgery. Patients who were intubated upon transfer to recovery room were included. Subjects were classied into two groups according to the duration of mechanical ventilation: prolonged mechanical ventilation (PMV) group (>72 hours) and non-PMV group (<72 hours). Results Among all pre-operative variables analysed, age of less than 4 years was almost three times associated with prolonged MV, body mass index of less than 11 kg/m2, a palliative type of surgery, white blood cell count of more than 15T per mm3 and a pre-operative chest-x-ray of hypovascularity. Among the post-operative factors, only the presence of cumulative positive balance was associated with an increased chance of prolonged mechanical ventilation. Intra-operatively, bypass time and presence of inotropic support were not both associated with the likelihood of prolonged mechanical ventilation. Other factors like age, sex, weight, height, risk strata, type of congenital heart disease, pre-operative laboratory work-up like blood pH, arterial pO2 and pCO2 did not signicantly contribute to an increased likelihood of prolonged mechanical ventilation. Nosocomial pneumonia, arrhythmia, the presence of non-infectious pulmonary complications, and low cardiac output were also not signicantly associated. Conclusion The present results suggest that preoperative arterial oxygen and hematocrit, intraoperative cardiopulmonary bypass time, indication for emergency procedure, postoperative arterial oxygen, white blood cell are risk factors for prolonged mechanical ventilation among children with congenital heart disease undergoing cardiac surgery. Prevention of postoperative PMV is an important task for the clinician. Identifying its risk factors will reduce incidence of prolonged mechanical ventilation and the involved serious complications.

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ACUTE RESPIRATORY INFECTIONS IN RURAL COMMUNITIES IN KENYA GORDON NYABADE Community Health, Go Fishnet Project, PO Box 2492 Kisumu, Kenya Introduction Acute respiratory infection (ARI) in children is a prevalent condition. In Kenya, 19% of all the cases seen in outpatient clinics and hospitals are acute respiratory infection and mostly in the urban communities. Methods The main objective of this study was to determine the prevalence and associated risk-factors of acute respiratory infections in under 5 years of age in Kibera Lindi. Therefore, we investigated the prevalence and whether, housing, overcrowding, smoke emissions and immunization status play a role in the acquisition of acute respiratory infections in Kibera Lindi slum village, which is located in Nairobi, Kenya. Results A retrospective cross-sectional survey was carried out in which the study population consisted of all children under ve years of age living in the village. The quota sampling procedure was used, targeting a sample size of 300 children and data was collected using an interview schedule. It was found that ARI was prevalent in the area (69.7%). In addition, among the risk factors of ARI studied were; mud walled houses (RR = 1.13), houses without windows (RR = 1.14), overcrowding (RR = 1.24), cooking fuel (rewood RR = 1.42, kerosene RR = 1.18), cooking near the bed (R = 1.35). The study revealed that acute respiratory infections and prevalent in Kibera Lindi Village and that; smoke emissions, overcrowding, housing played a role in its acquisition. Conclusion The study revealed that acute respiratory infections and prevalent in Kibera Lindi Village and that; smoke emissions, overcrowding, housing played a role in its acquisition. It was not clear whether the childrens immunization status had a role in acquisition of acute respiratory infections.

CLINICAL STUDY OF PENICILLIN SENSITIVE STREPTOCOCCUS PNEUMONIA (PSSP) PNEUMONIA, PENICILLIN INSENSITIVE STREPTOCOCCUS PNEUMONIAE (PISP) PNEUMONIAE AND PENICILLIN RESISTANT STREPTOCOCCUS PNEUMONIAE (PRSP) PNEUMONIA SADAO TAMADA, OKIMOTO NIRO, SAOKA NAOKO, YAGI SHINICHI, KISHIMOTO MICHIHIRO, NANBA FUMIYO, HAYASHI TOSHIHIRO Respiratory Disease Center, Kawasaki Hospital, 2-1-80 Nakasange Okayama City, Japan Introduction Streptococcus is the leading bacterial cause of community acquired pneumonia. The high incidence of streptococcus pneumoniae pneumonia can often cause fatal sepsis. The more resistant antibiotics become, the more important the study of proper streptococcal pneumonia chemotherapy. Methods We studied cases diagnosed as streptococcus pneumoniae pneumonia from 2005 to 2010 and were treated with antibiotic (SBT/ABPC). We investigated the patient background (age, sex) and the results of sputum culture, bacterial sensitivity against antibiotic and evaluated the effectiveness of chemotherapy. Results Twelve cases were diagnosed as streptococcus pneumoniae pneumonia according to the results of urine rapid streptococcus pneumoniae antigen test from 2005 to 2010 and treated with antibiotic (SBT/ABPC). Four cases of twelve were isolated streptococcus pneumonia. These four were evaluated as to their the sensitivity to penicillin (PSS:1, PPIS:1, PRSP:2). Conclusion The study of the effectiveness of chemotherapy showed that moderate and high doses of ABPC, which are recommended by the Japanese respiratory society, were effective in all cases. At the present, moderate and high doses of ABPC are still effective antibiotic therapy against streptococcus pneumoniae pneumonia. Efcient diagnosis with antigen and proper prescription of penicillin will prevent antibiotics from becoming more resistant.

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ANTIBIOTIC PRESCRIPTIONS IN RESPIRATORY INFECTIONS. THE PRIMARY CARE RESPIRATORY GROUP IN SRI LANKA ANTHONY SENEVIRATNE, SARATH PARANAVITANE, SENETH SAMARANAYAKE, PRASANNA SIRIWARDENE, CHANDANA GALAPATHI, THILAK SILVA, SB SERASINGHE, VAJIRA PAERERA, SANATH HETTIGE Family Medicine, University of Sri Jayawardenepura, 54/10 Chakkindarama Road, Ratmalana, Sri Lanka Introduction Respiratory symptoms are most frequent reasons for consultation. A study by The Primary Care Respiratory Group Sri Lanka in 2007 to identify the reasons for encounter in general practice in Sri Lanka showed that the respiratory problems were the commonest reason for encounter accounting to 30% patient load. It is a known fact that antibiotics are commonly prescribed for patients with respiratory symptoms. This was one of the initial studies conducted in order to nd out the antibiotic prescribing patters in general practice. This will provide an opportunity to identify the common reasons for the use of antibiotics in respiratory infections. This will give an opportunity to formulate antibiotic guidelines in respiratory infections. The aim of this study was to ascertain the morbidity pattern of respiratory problems in general practice, the variability of antibiotic use and reasons for its use. Methods A cross-sectional study was carried out in the clinics of 14 general practitioners (GPs). The GPs were selected randomly from the members of the college of general practitioners of Sri Lanka. Among the collected variables were: presenting symptoms, type of respiratory infection, antibiotic prescription, co morbidity, qualication and experience of the prescribing doctor. Results A sample of 3814 respiratory infections was studied. Antibacterial agent treatment was prescribed in 62% of them. The common reasons for encounter were cough (43%), nasal congestion and runny nose (13%) and wheezing (11%). Antibiotics were prescribed in 62% of patients with cough, 47% in nasal congestion and 43% in wheezes. The use of antibiotics varying according to the infection between 92% in acute bronchitis, 50% in common cold and 50% in asthmatics. The most commonly used antibiotics were in the penicillin group accounting to 56%, macrolides 18% and cephalosporins 14%. Out of the penicillins amoxicillin (52%) amoxicillin-clavulanate (38%) and oral penicillin 8%. Conclusion There is excessive use of antimicrobial drugs in acute respiratory infections, and the majority are used for viral infections. There is indiscriminate use of broad spectrum antibiotics, which are valid in some infections but clearly inappropriate in others. Similarly, there are important differences in the choice of antibiotics and their degree of appropriateness among general practitioners.

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DISSEMINATED CRYPTOCCOCAL INFECTION IN AN IMMUNOCOMPETENT HOST: A CASE REPORT RUBY NOLIDO, ABUNDIO BALGOS Pulmonary Section, UP-PGH, Taft Avenue, Manila, Philippines Introduction Cryptococcosis is a global invasive mycosis that is associated with signicant morbidity and mortality. It occurs predominantly in T-cell mediated immune defects especially aids and transplant-related immunosuppression, but only rarely causes disseminated infection in healthy individuals. Results This reports a case of disseminated cryptococcal infection in an immunocompetent host. This is a case of a 52-year old Filipino who presented with chronic cough and fever with chest radiograph showing homogenous opacity at the right lower lobe. He was treated initially as a case of pneumonia and pulmonary tuberculosis. He was subsequently admitted due to left sided weakness and focal seizures with Cranial CT Scan and MRI demonstrating multiple brain lesions. Became a diagnostic dilemma and thus the patient underwent several non-invasive and invasive diagnostic procedures namely: video-assisted bronchoscopy with transbronchial biopsy, and broncheoalveolar lavage, CT scan guided aspiration biopsy and lumbar tap. He was nally found to have cryptococcosis after a repeat transthoracic CT scan-guided aspiration biopsy which showed on PAS and GMS stains: positive for varying sizes of encapsulated fungal yeasts which display budding and embedded within necrotic material. There was resolution of symptoms and decrease in the size of the pulmonary mass after treatment with oral uconazole.

ROLE OF ORAL RESPIRATORY QUINOLONES IN THE TREATMENT OF COMMUNITY-ACQUIRED PNEUMONIA AT OUTPATIENT CLINIC HIRAI AYUKO, HIDEKI KANAZAWA, SYUJI KANAZAWA Kanazawa Clinic, Kobe, Japan Introduction Respiratory quinolone is an antimicrobial agent that exhibits potent activity against a range of pathogens which cause community-acquired pneumonia (CAP) such as Streptococcus pneumonia, Haemophilus inuenzae, Moraxella catarrhalis and atypical pathogens. We investigated the efcacy of oral respiratory quinolones for CAP in outpatient clinic. Methods Retrospective data of 19 patients with CAP treated by oral respiratory quinolone at our clinic between January 2009 and July 2010 were collected by medical chart review. CAP was diagnosed on the basis of chest radiograph or/and computed tomography ndings. Results Mean age of the patients was 43.6 (range 2364 years), 17 males and 2 females. 3 patients had diabetes mellitus and 3 had chronic pulmonary disease (2 bronchial asthma, 1 emphysema). 11 patients were treated with Moxioxacin (400 mg, once-daily), 6 with Levooxacin (500 mg, once-daily) and 2 with Garenoxacin (400 mg, once-daily). Only 1 patient with diabetes mellitus and mental retardation was hospitalized by hypoxia after 5 days treatment of respiratory quinolone. 1 patient with emphysema and 1 with diabetes mellitus needed additional intravenously antibiotics therapy. Durations of antimicrobial therapy were from 5 to 14 days (mean 8 days) Patients came to the clinic average 2.6 days for the treatment of CAP. Mild gastro-intestinal adverse drug reaction was observed (1 diarrhea, 1 nausea), but no serious adverse event. Conclusion Once-daily oral respiratory quinolone therapy is practical and tolerable for patients with CAP at outpatient clinic.

PD 0906

BRONCHOALVEOLAR LAVAGE GALACTOMANNAN IN DIAGNOSIS OF CHRONIC PULMONARY ASPERGILLOSIS KOICHI IZUMIKAWA, TOMO MIHARA, TAKAHIRO TAKAZONO, TAIGA MIYAZAKI, MASAFUMI SEKI, HIROSHI KAKEYA, YOSHIHIRO YAMAMOTO, KATSUNORI YANAGIHARA, SHIGERU KOHNO Nagasaki University Graduate School of Biomedical Sciences, Department of Molecular Microbiology and Immunology, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan Introduction Diagnosing chronic pulmonary aspergillosis (CPA) is problematic and no reliable diagnosing methods were established. Detection of Aspergillus galactomannan (GM) antigen in serum by an enzyme-linked immunosorbent assay showed unsatisfactory sensitivity and specicity. The purpose of this study was to evaluate bronchoalveolar lavage (BAL) GM detection and to assess the utility of the assay in the diagnosis of CPA. Methods We reviewed all cases of CPA and non-CPA patients in Nagasaki University Hospital, Nagasaki, Japan who had BAL uid and serum tested for GM between August, 2005 and March, 2009. BAL was performed according to the methods of individual pulmonologists. The bronchus of the lobe in which newer consolidation was imaged by chest radiographs including CT scan was wedged, and 2050 ml of 0.9% sterile saline solution was instilled with a syringe. The total volume of saline solution instilled into the lung was typically 30150 ml, and 10 to 100 ml of BAL uid was recovered. The Platelia Aspergillus enzyme immunoassay was performed at according to the manufacturers procedures. Results A total of 19 CPA and 126 non-CPA patients were investigated. Mean value of BAL GM antigen was 4.676 (range; 0.062 to 14.120) and 0.4299 (range; 0.062 to 9.285) in CPA and non-CPA patients, respectively. Mean value of serum GM antigen was 1.473 (range; 0.232 to 5.397) and 0.864 (range; 0.028 to 8.956) in CPA and non-CPA patients, respectively. The sensitivity, specicity, and positive and negative predictive values for BAL GM testing at a cutoff of 1.0 (0.5) were 52.6 (63.2)%, 92.1 (82.5)%, 50.0 (34.3)%, and 92.8 (94.5)%, respectively. The sensitivity, specicity, and positive and negative predictive values for serum GM testing at a cutoff of 1.0 (0.5) were 47.4 (78.9)%, 73.0 (54.0)%, 20.9 (20.5)%, and 90.2 (94.4)%, respectively. The receiver operating characteristic test indicated the sensitivity of 73.7% and specicity of 75.4% at cutoff 0.7 in BAL GM and area under the curve was larger in BAL GM compared to serum GM. Conclusion BAL GM testing showed reasonable sensitivity and specicity at the cutoff of 0.4 and the combination evaluation of serum and BAL GM might enhance the diagnosing rate of CPA.

Conclusion This case report presented that cryptococcal infection may occur in an immunocompetent host. The delay in the diagnosis is secondary to the non-specicity of signs and symptoms, the insidiousness of the course and the absence of characteristic radiographic features. The case is also reective of a possible Cryptococcus gattii infection that usually causes 7080% of cryptococcal infection in immunocompetent hosts with an increased risk of developing intracerebral mass lesions or Cryptococcomas. It is more common in tropical regions like the Philippines and generally with better prognosis.

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PD 0907

PD 0909

WHAT ARE THE MOST USEFUL PROGNOSTIC SCALE AND BIOMARKER AT THE FIRST VISIT IN COMMUNITY-ACQUIRED PNEUMONIA? YU KASAMATSU, TOSHIMASA YAMAGUCHI, TAKASHI KAWAGUCHI, MIKIKO SHIBATA, TOMOKO MIYASHITA, TOMOYUKI NAKAMURA, KEIKO YAMAGAMI, KATSUNOBU YOSHIOKA, MASAHITO IMANISHI Osaka City General Hospital, 2-1-10-#80, Toyohidecho Moriguchi-shi, Osaka, Japan Introduction Useful prognostic scales enable us to predict mortality and evaluate severity in community-acquired pneumonia (CAP). However, the usefulness of the biomarkers as a means of predicting mortality and evaluating severity remains unclear in CAP. Methods The primary aim of this study was to investigate whether biomarkers on the rst medical examination predict 30-day mortality. The second aim was to investigate the usefulness of Procalcitonin (PCT) semi-quantitative kit which divide the PCT levels into 4 categories (<0.5 ng/ml; > or =0.5<2.0 ng/ ml; > or =2<10 ng/ml; > or =10 ng/ml) and A-DROP scale (1, confusion; 2, blood urea nitrogen >21 mg/dl or appearance of dehydration; 3, percutaneous oxygen desaturation <90%; 4, systolic blood pressure <90 mmHg; 5, age >70 years for men, >75 years for women). A prospective cohort study in two hospitals in Osaka City Groups was designed. PCT levels by using of semiquantitative kit and C-reactive protein levels were measured at the rst visit. Comprehensive examinations were conducted for determination of disease severity based on A-DROP, PSI (Pneumonia Severity Index) and CURB65. A total of 144 hospitalized CAP patients were enrolled. Results The 16 patients (11.1%) were died. PCT levels in those patients were signicantly higher than those who survived. The diagnostic value of markers and prognostic scales to predict 30-day mortality was assessed with AUCs, with following results: CRP, 0.56; PCT, 0.79; CURB65, 0.88; A-DROP, 0.88; PSI, 0.91. The AUCs of PCT and CRP for diagnostic value to predict 30-day mortality calculated by ROC analysis were 0.79 and 0.56, respectively (P < 0.001). The AUCs of PCT and PSI for diagnostic value to predict 30-day mortality calculated by ROC analysis were 0.79 and 0.91, respectively (P = 0.05). Adding PCT to A-DROP increased the AUC from 0.88 to 0.91, that of CURB65 from 0.88 to 0.91. Adding CRP to CURB65 or ADROP did not signicantly increase the AUCs. Conclusion A-DROP and PCT at the rst visit are useful scale to predict 30-day mortality. Adding PCT levels by using of semi-quantitative kit to ADROP and CURB65 scales can be useful for prediction of 30-day mortality.

GIANT BULLAE RISKY AKAPUTRA, BOEDI SWIDARMOKO Persahabatan Hospital Division Pulmonology, Jakarta, Indonesia Introduction Giant bullae is a rare case, histologically referred to as the presence of emphysematous areas and is one of the most common cause of spontaneous pneumothorax. Methods Patient man 29 yo referred to Persahabatan Hospital with complain chest pain, sometimes breathlessness and dry cough. Patient had history of smoking 10 years 12 cigarettes per day. There was history of taken ATA for 1 year and there is no improvement and 1 month after that patient performed chest tube and there was no improvement. Physical examination found that asymmetrical thorax, right hemithorax was left, weakened right fremitus, hypersonor in right lung and weakened breathsound in right lung. Laboratory nding there is increasing of ESR, BGA is light hypoxemia, Chest x ray there is hyperluscent area almost in all of right lung and the apex of the left lung. Spirometry found that moderate restriction and light obstruction. Patient diagnosed with giant bullae and planned for bullaectomy. Results After resection, the patient showed good condition and better performance marked by improvement of 6 mwt. Discussion DeVries dan Wolfe had classied Giant bullae in 4 category. The classication of bullae is useful to evaluate patients as candidates for surgery and to predict the potential functional outcome. The classication are single large bulla with normal underlying lung, multiple bullae with underlying normal lung, multiple bullae with underlying lung diffusely emphysematous and multiple bullae with underlying lung affected by other diseases. Conclusion Diagnosis of bullae is based on anamnesis, physical examination, laboratory nding and chest x ray to determine decision for surgery. In this era, We have developed a variety of surgical options that can be done for the bullae. Handling is good will provide satisfactory results, especially in terms of improved quality of life of patients.

PD 0910

BRONCHIOLITIS WITH STREPTOCOCCUS PNEUMONIAE: A CASE REPORT YASUSHI RYUJIN, IZUMIYA SAKURA, SHIGEMORI WATARU, WADA HIROSHI, YAMADA HIDETO, OGUMA TETSUYA, OSAWA MAKOTO, NAGAO TAISHI, NAKANO YASUTAKA Division of Respiratory Medicine, Department of Internal Medicine, Shiga University of Medical Science, SetaTsukinowa-cho, Otsu, Shiga, Japan Introduction Streptococcus pneumoniae (S. pneumoniae) nds its ecologic niche in colonizing the nasopharynx, but it causes infection of the middle ear, sinuses, trachea, bronchi, and lungs by direct spread of organisms from the nasopharyngeal site of colonization. S. pneumoniae is the most common cause of community-acquired pneumonia and is responsible for high morbidity and mortality worldwide. Usually, S. pneumoniae causes lobar or bronchial pneumonia in adulthood, and rarely causes bronchiolitis. Here, we report a case of bronchiolitis caused by S. pneumoniae. Methods A 67-year-old woman, who had been suffered from rheumatoid arthritis, complained of dyspnea and visited her general practitioner. Because of her hypoxemia, she was immediately transferred to our hospital. Results Chest computed tomography demonstrated bilateral centrilobular nodules and emphysematous lesions, but no signs of pneumonia. Pneumococcal urinary antigen was positive, and S. pneumoniae was identied from her sputum. We diagnosed her disease as bronchiolitis due to S. pneumoniae. Piperacillin/tazobactum (18.0 g/day, intravenously) and Garenoxacin mesilate hydrate (400 mg/day, orally) were administered to her. Accordingly, she recovered and her lung shadows disappeared. Conclusion Viral or mycoplasmal infections, inhalation injury, drug-induced processes, chronic inammatory disorders, and lung transplantation are wellknown causes of bronchiolitis in adulthood. However, bacterial infections are rare cause of bronchiolitis. Indeed, there are some reports that bacterial infection caused bronchiolitis in adulthood. Most of these cases were improved by administration of antibiotics, but some died during their acute phase. Early diagnosis using rapid diagnostic tests, such as a pneumococcal urinary antigen test, may lead a prompt use of appropriate antibiotics and may improve the prognosis of these patients.

PD 0908

THE EFFICACY AND SAFETY OF TRIPLE THERAPY IN SEVERE NOVEL INFLUENZA A (H1N1) PNEUMONIA YONG SOO KWON, HONG-JOON SHIN, SU YOUNG CHI, KYU SIK KIM, YU IL KIM, SUNG CHUL LIM, YOUNG CHUL KIM Chonnam National University Hospital, 671 Je Bong Ro Dong-gu Gwangju, South Korea Introduction Little information exists regarding the efcacy and safety of triple therapy consisting of oseltamivir, ribavirin and amantadine for severe novel inuenza A (H1N1) pneumonia. Methods We retrospectively reviewed 16 patients with laboratory-conrmed severe novel inuenza A pneumonia between 24 August, 2009 and 21 January, 2010 at Chonnam National University Hospital. Results Of the 16 patients, 9 (56%) were treated with triple therapy and 7 (44%) were treated with oseltamivir monotherapy. Adverse drug effects were more frequently developed in triple therapy group (7/9 [78%]) than oseltamivir monotherapy group (0/7 [0%], p = 0.003). Of 7 patients who had adverse drug effects, 3 were withheld ribavirin and/or amantadine due to 1 anemia, 1 thrombocytopenia, and 1 neutropenia. However, there were no differences between triple therapy and monotherapy in hospital stay (16.0 [13.021.5] in triple therapy group vs. 10.0 [6.018.0] in monotherapy group, p = 0.174) and mortality (3 [33%] in triple therapy group vs. 2 [28.6%] in monotherapy group, p = 0.635). Conclusion The triple therapy was not superior in the treatment efcacy and has more adverse drug effects than oseltamivir monotherapy for severe novel inuenza A pneumonia.

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PD 0911

PD 0913

A RARE CASE OF PNEUMOCYSTIS JIROVECII PNEUMONIA WITH NODULAR SHADOWS IN ADULT T-CELL LEUKEMIA PATIENT KOICHI IZUMIKAWA, KATSUJI HIRANO, TOMOYUKI KAKUGAWA, EISUKE SASAKI, AKITOSHI KINOSHITA, MASAFUMI SEKI, KOICHI IZUMIKAWA, HIROSHI KAKEYA, YOSHIHIRO YAMAMOTO, KATSUNORI YANAGIHARA, SHIGERU KOHNO Nagasaki University Graduate School of Biomedical Science, Department of Molecular Microbiology and Immunology, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan Introduction Pneumocystis jirovecii pneumonia (PCP) is one of important respiratory infections among the immunocompromised patients with HIV/AIDS, malignancies, leukemia, collagen disease, steroid administration and/or organ transplantation. Diffuse ground glass opacities (GGO) in chest X-ray lms with hypoxia are common clinical signs and radiological signs of PCP. We encountered a very rare case of PCP with apparent multiple nodular shadows and report here with a review of recent literatures. Methods Sixty ve-year old male with cough, general malaise and dyspnea was admitted to our hospital for treatment. Hypoxia (SpO2 91% at room air) and ne crackle in whole anterior chest were recognized and diffuse GGO in whole lungs with two nodular lesions in right and left lower lobes (1020 mm in diameter) were seen in chest computed-tomography. Adult T-cell leukemia (ATL) with PCP were diagnosed with the ndings of ower cell in blood smear examination, high value of (1,3) -D-glucan, radiological ndings of diffuse GGO in X-ray lms and hypoxia. Due to severe status of the patient, bronchoberscopy examination was not performed before the treatment. Predonisolone and sulfamethoxazole/trimetoprim were immediately administered. The patient gradually recovered and GGO was reduced. However two nodular regions remained same and transbronchial lung biopsy (TBLB) was performed on day 20 from admission. The pathological ndings revealed body of P. jirovecii by Grocott-Gomori stain and PCR for P. jirovecii was positive. Conclusion Typical PCP radiological ndings are diffuse GGO with severe hypoxia. In current case, we performed TBLB for ruling out of invasion of ATL cells to lung parenchyma, however, pathological ndings indicated body of P. jirovecii with the positive PCR. Cases of PCP with multiple nodular shadows are rarely reported before and we should realize that PCP is one of differential diagnosis in the immunocompromised patients with nodular shadows.

CLINICAL MANIFESTATIONS AND RISK FACTOR FOR DEATH OF PNEUMOCYSTIS PNEUMONIA IN PATIENTS WITHOUT HIV INFECTION NOBUHIRO ASAI, YOSHIHIRO OHKUNI, RYO MATSUNUMA, KEI NAKASHIMA, KATSUTOSHI ANDO, YOSHIHITO OTSUKA, TAMAO NAKASHITA, SHINJI MOTOJIMA, NORIHIRO KANEKO Kameda General Hospital, 929 Higashi-cho, Kamogawa City, Chiba, Japan Introduction While pneumocystis pneumonia (PCP) is common in patients with AIDS, it could occur in patients with other causes of immunodeciency as malignancy, rheumatic disease or steroid/immunosuppressor users. Methods To evaluate clinical pictures and fatal risk factors in PCP patients without HIV, we retrospectively reviewed all patients of PCP without HIV. Chest radiographs were reviewed by both pulmonologist and radiologist. Statistics were used by Fishers exact test and analysis of variance. P-value < 0.05 was considered to be statistically signicant. Results A total of 25 patients were eligible in this study. Fourteen patients (56%) had rheumatic disease and 12 patients (48%) had malignancies. While seventeen patients (68%) underwent long term steroids and/or immunocompressor administration, only 2 patients (8%) received PCP prophylaxis. The main symptoms on initial visit were fever (56% n = 14), sputum (16% n = 4), dyspnea (24% n = 6), and cough (36% n = 9). Three patients (12%) were asymptomatic and 13 patients (52%) had one of these symptoms. Chest radiologic ndings showed bilateral inltrates (52% n = 13), effusion (44% n = 11) or consolidation (32% n = 8). Eighteen patients (72%) developed respiratory failure and 11 patients (44%) died. Comparing survival and fatal groups, patients in the fatal group had longer days between diagnosis and starting anti-PCP therapy (5 vs 13 days, p < 0.05), higher frequency of bilateral inltrates (10 vs 3, p < 0.001) and effusion (8 vs 3, p < 0.001) by HRCT than the survival group. Both KL-6 and LDH values were statistically higher in fatal group than in survival group. Conclusion It is possible that PCP without HIV revealed no respiratory symptom. Higher LDH, KL-6 values on chemistry and bilateral inltrates and effusion by chest radiographs might be fatal risk factor for death in PCP without HIV. Therefore, PCP requires early diagnosis followed by anti-PCP therapy before patients presents dyspnea or chest radiograph revealing bilateral inltrates or effusion. Thus, all clinicians should consider the possibility of PCP in patients with immunodeciency other than HIV such as malignancies or rheumatic diseases.

PD 0912

CULTURE AND SENSITIVITY OF SPUTUM TO DETERMINE MICROBIAL PATTERN IN ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN DR. SARDJITO HOSPITAL YOGYAKARTA INDONESIA EKO BUDIONO, IKA TRISNAWATI, SUMARDI, BAMBANG SIGIT RIYANTO Division of Pulmonology, Department of Internal Medicine Faculty of Medicine Gadjah Mada University/Dr. Sardjito Hospital, Yogyakarta, Indonesia Introduction Bacterial infection is a major cause of acute exacerbation of chronic obstructive pulmonary disease (COPD) and even the primary cause of death.1,2 Antibiotic must be given as soon as possible empirically before denite therapy.3 Therefore, we must know the most common organism and the most sensitive antibiotics in our medical facility. Methods Retrospective descriptive. Results There were 82 isolates and most of them were sensitive to cefotaxime. The most common bacteria and sensitivity to cefotaxime were following: Klebsiella pneumonia (33%; 96%), Streptococcus (30%; 91%), Pseudomonas aeruginosa (17%; 71%) Enterobacter (8%; 71%), Neisseria catharralis (6%; 100%) Staphylococcus epidermidis (6%; 100%). Chronic bronchitis (54%) were more frequent as the underlying disease than emphysema (46%). Nine percent patients died from COPD grade III. Conclusion The most common bacteria that is found in the exacerbation of COPD is Klebsiella pneumonia (33%) and the most sensitive antibiotics is cefotaxim (cephalosporin generation III). Cefotaxime should be considered to treat exacerbation of COPD empirically. References 1. Seaton A, Seaton D, Leitch AG. Crofton and Douglass Respiratory Diseases, 4th Edition. Wiley-Blackwell: Oxford, 1998. 2. Miraveitlles M, Espinos C, Laso EF, Martes JA, Maldonado JA, Gallego M. Relationship between bacterial ora in sputum and function impairment patients with acute exacerbation of COPD. Chest 1999; 116: 406. 3. Murphy TF, Sethi S. Bacterial infection in chronic obstructive pulmonary disease. Am Rev Respir Dis 1992; 146: 106783.

PD 0914

EVALUATION OF 323 PATIENTS SURGICALLY TREATED FOR THORACIC HYDATIDOSIS DURING LAST 20-YEAR PERIOD TURGUT ISITMANGIL, NURETTIN YIYIT, RAUF GORUR, ORYAL ERDIK, AKIN YILDIZHAN, FATIH CANDAS, SABAN SEBIT, HABIL TUNC, SEFA SELCUK GATA Haydarpasa Egitim Hastanesi, Gogus Cerrahisi Servisi, Cerrahi Bina Kat, Uskudar, Istanbul, Turkey Introduction Human infection with the larval stage of the canine tapeworm Echinococcus granulosus is one of the most important helminthic pulmonary diseases. Methods The records of 323 patients (302 males, 21 females; mean age 24.44 years; range 6 to 72 years) who were diagnosed to have hydatid cyst and treated surgically in our clinic between January 1990 and December 2009 were evaluated retrospectively. The most common presenting symptoms were cough, expectoration and chest pain. Thoracotomy in 311 patients, bilateral staged thoracotomies in eight patients with bilateral hydatid cysts, median sternotomy in one patient with bilateral hydatid cysts, and video-assisted thoracic surgery in three patients were used as surgical approach. Results Among 322 patients out of 323 patients there were 399 intrapulmonary hydatid cysts. Two hundred twenty-one of these 399 intrapulmonary cysts were in the right lung and 178 in the left lung. The other patient had bilaterally 55 small pulmonary cysts. The most common cyst localizations were lower lobes of each lung. Twenty-eight out of 69 ruptured cysts had been infected. Intrathoracic extrapulmonary hydatid cysts were detected in 15 patients. There were accompanying hydatid cysts in the liver in 52 patients, in spleen in one patient and in left kidney in one patient. Small wedge resection was performed in 28 patients, segmentectomy in ve patients and lobectomy in three patients. Other patients were treated with conservative surgical procedures as cystotomy or enucleation. There was no peri- or postoperative mortality. Conclusion Surgical removal of the cysts is the treatment of choice for thoracic hydatidosis and conservative surgical approaches are safe and effective in most patients.

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PD 0915

PD 0917

AN AUTOPSY CASE OF INVASIVE PULMONARY ASPERGILLOSIS WITH NOCARDIOSIS DURING STEROID TREATMENT TATSURO HIRAYAMA, AKIRA KONDO, KOICHI IZUMIKAWA, MASAFUMI SEKI, HIROSHI KAKEYA, YOSHIHIRO YAMAMOTO, KATSUNORI YANAGIHARA, YUICHI INOUE, SHIGERU KOHNO Nagasaki University Graduate School of Biomedical Sciences, Department of Molecular Microbiology and Immunology, 1-7-1 Sakamoto, Nagasaki 8528501, Japan Introduction The incidence of mycoses such as cryptococcosis, aspergillosis and candidiasis has been increasing due to accession of susceptible individuals. Nocardiosis is also an opportunistic infection in immunocompromised hosts. We encountered a case of invasive pulmonary aspergillosis with co-infection of nocardiosis during steroid treatment for vasculitis. Methods Seventy three-year old female with persistent cough, hemosputum with progressive renal dysfunction was referred to our hospital. Although antineutrophil cytoplasmic autoantibody was negative, vasculitis was clinically diagnosed with increased density around airway in chest computed-tomography examination. Steroid pulse therapy (methylpredonisolone 1000 mg/day for three days) following continuous administration of decreased amount of steroid was administered and effective. The patient once recovered, however, hemosputum was appeared again when 7.5 mg/day of steroid. Although steroid was increased to 20 mg/day, no clinical response was seen and multiple cavitary lesions were emerged. Transbronchial lung biopsy was immediately performed and pathological ndings revealed granulomatous changes and hemorrhagic necrosis. Aspergillus fumigatus and Nocardia vinacea were retrospectively isolated. Both of serum Aspergillus ELISA antigen and (1, 3) beta-D glucan were positive. Aspergillus antibody was negative. Although combination of meropenem, micafungin, minocycline and sulfamethoxazole/trimetoprim were intensively administrated for aspergillosis and nocardiosis, she was dead. Results Autopsy revealed that 1) systemic invasive aspergillosis (lung, heart, liver, spleen, kidney and thyroid), 2) pulmonary nocardiosis (localized in left lower lung lobe), and 3) no evidence of vasculitis were found. Conclusion Systemic invasive aspergillosis and pulmonary nocardiosis were the cause of death in this case. There are only few reports of aspergillosis with nocardiosis. It is required to make precise diagnosis of infectious diseases and initiate an appropriate treatment especially in immunocompromised hosts.

ANALYSIS OF THE FATAL CASES DUE TO PNEUMOCYSTIS PNEUMONIA IN HIV-INFECTED PATIENTS DAISUKE KASAI, TAKUMA SHIRASAKA, YOSHIHIKO OGAWA, HIROKI BANDO, KEISHIRO YAJIMA, TOMOHIRO TANIGUCHI, DAI WATANABE, YASUHARU NISHIDA, TOMOKO UEHIRA Department of Infectious Disease, Osaka National Hospital, 2-1-14 Hoenzaka Chuo-ku Osaka, Japan Introduction Pneumocystis pneumonia (PCP) has been recognized as an important pathogen of immunocompromised patients, especially patients infected with human immunodeciency virus (HIV), and most common opportunistic infection in patients with a CD4 count under 200. HIV infection is also often detected with the onset of PCP. While PCP with HIV-infected patients were reported to be better prognosis than non-HIV patients, severe pneumocystis pneumonia is still one of the most important cause of death in HIVinfected patients. In this study, we analyzed the fatal cases with PCP in our hospital. Methods We reviewed retrospectively clinical and laboratory data from initially detected case of PCP in HIV-infected patients from 1998 through August 2010 in our hospital. Results The number of patients was 204, with 193 males and 11 females. The racial composition include 200 Japanese, 1 Australian, 1 African, 1 nonJapanese Asian, and 1 European. The number of fatal outcomes was 17, with all being Japanese. Comparing improved with fatal outcomes, the mean age in the improved group was 40.5 years (median: 38 years), while that in the death group was 45.6 years (median: 50 years). Laboratory data showed that the average CD4 count on admission was 43.3 in the improved group and 11.4 in the death group, revealing that the values were signicantly lower in the death group. The average LDH on admission was 308.4 in the improved group and 497.5 in the death group. The average KL-6 was 2054.4 in the improved group and 5240.7 in the death group. Values of both parameters were higher in the death group. Meanwhile, the average -D-glucan levels were 1393.5 in the improved group and 1287.7 in the death group, revealing no signicant differences between the group. Analysis of fetal cases showed that 16 of 17 cases required oxygen administration on admission, reecting the disease progression. Steroid pulse therapy was inducted in 9 of 17 cases before the diagnosis of PCP was conrmed. Conclusion Compared with improved group, trends of advanced age, low CD4 counts, high LDH, and high KL-6 were observed in the death group. In many cases, PCP was exacerbated by usage of high dose steroids before introducing treatment for PCP. An appropriate and early diagnosis and effective treatment are very important for PCP in HIV-infected patients.

PD 0916

DIRECT HEMOPERFUSION WITH POLYMYXIN B-IMMOBILIZED FIBRE COLUMN TO TREAT SEVERE PNEUMONIA WITH INFLUENZA A (H5N1) VIRUS SHINYU IZUMI, TAKASAKI JIN, NGUYEN DANG TUAN, DAO XUAN CO, MANABE TOSHIE, NGUYEN GIA BINH, NGO QUY CHAU, TRAN THUY HANH, KUDO KOICHIRO Department of Respiratory Medicine/Disease Control and Prevention, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, Japan Introduction As of July 2010, more than 500 people worldwide have been documented as having contracted the highly pathogenic avian inuenza A (H5N1) virus. Many patients progress rapidly to acute respiratory distress syndrome (ARDS), which is characterized by pathological lesions of diffuse alveolar damage (DAD), and the cumulative case-fatality rate has reached a high of approximately 60%. Methods Direct hemoperfusion with polymyxin B-immobilized bre column (PMX-DHP) has demonstrated a benecial effect on the respiratory condition (PaO2/FiO2 ratio) in patients with ARDS. We decided to perform PMX-DHP as an inammation-modulating therapy for a particularly severe case with viral pneumonia caused by avian inuenza A (H5N1) virus. Results No serious adverse effects were observed and the PMX-DHP treatment markedly improved oxygenation in acute respiratory distress syndrome (ARDS) with PaO2/FiO2 ratio of 43. The levels of inammatory cytokines in the patients sera signicantly decreased 24 hours after the start of PMX-DHP. The patient was weaned from mechanical ventilation and discharged. Conclusion Despite the limitation of a single case report, this patients recovery should encourage further investigation of the efcacy of PMX-DHP for severe pneumonia with A (H5N1) virus, which could be a future pandemic strain.

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THE OUTBREAK PANDEMIC A (H1N1) INFLUENZA 2009 NINO JESSIELITO DOYDORA, NOEL ESTRELLA, ALFONSO BARRIENTOS JR, RICARDO SALONGA, JOSE EDZEL TAMAYO Department of Internal Medicine, Section of Pulmonology, University of Perpetual Help DALTA Medical Center, Las Pinas, Philippines Introduction From 1918 to 2009, different evolutions and antigenic shifting of Inuenza virus have occurred. March 2009, in Mexico, a new strain of Inuenza virus was reported. In the Philippines, the rst conrmed case in the country is a 10 year old girl presenting with u like symptoms, who arrived on May 18 from the U.S. In 2009, DOH reported 5,212 conrmed cases and 30 deaths of swine u. To present case series of Pandemic A(H1N1) 2009 virus seen at UPHDMC. To determine the clinical and epidemiologic prole of these cases. To present our Task Force Action Plan in preparation for the pandemic disease. Methods This is a descriptive, analytical study of patients seen at emergency department and hospitalized patients of UPHDC suspected of having Pandemic A(H1N1) infection. Results Our center reported 40 patients suspected to have pandemic A(H1N1) infections referred to RITM (Research Institute for Tropical Medicine) for conrmation. Of these, 24 (60%) subsequently tested positive for the infection, consisting of 13 adults and 11 pediatric patients. All of them presented with acute febrile illness and u-like symptoms and one had diarrhea as well. Five of these who tested positive were in-patients, consisting of 4 females and 1 male. Of these, 1 have travel history abroad and 3 have exposure to arriving relatives from abroad with u-like symptoms. Three of them have asthma as co-morbidity. Four of them have normal chest radiograph. One have pneumonia on chest radiograph requiring antibiotic therapy. The latter also developed congestive heart failure. Advance age and multiple co-morbidity is associated with longer hospital stay and more complicated hospital course. Even before the WHO declaration of pandemic, our institution have devised Inuenza A(H1N1) Task Force Action Plan whose activities include massive information drive, education and training of frontliners, constant communication with management for the resources and manpower needed and the creation of a respiratory unit outside the hospital premises to minimize mixing of respiratory and non-respiratory cases thus further diminishing the risk of transmission of H1N1. Conclusion The conrmed cases of Pandemic A(H1N1) 2009 seen in our institution presented with u-like symptoms and were all mild cases. An effective Task Force Action Plan is mandatory to minimize the impact of the disease.

CLINICAL FEATURES OF PULMONARY CYRPTOCOCCOSIS IN NON-AIDS PATIENTS YOUNG JUNE JEON1, CHI YOUNG JUNG1, SEUNG ICK CHA2, DAE SUNG HYUN3, SEUNG WOOK JUNG4, YEON JAE KIM4 1 Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea, 2Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea, 3Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea, and 4Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea Introduction Cryptococcosis is a infectious disease, caused by inhalation of cryptococcal particles into the lungs, and can cause infection in central nervous system via hematogenous disseminations and thus systemic infection is possible. Cryptococcal infections most commonly occur in immunocompromised hosts, such as acquired immunodeciency syndrome (AIDS). Isolated pulmonary cryptococcosis in non-AIDS patient is relatively rare, so we report pulmonary cryptococcosis in non-AIDS patients with analyzing their clinical features. Methods We studied 14 cases of pulmonary cryptococcosis, diagnosed in the teaching hospitals in Daegu, Korea from January 2003 to December 2008, and we reviewed the 43 cases of pulmonary cryptococcosis reported in Korean articles, which were published from January 1984 to June 2009. We retrospectively analyzed the clinical features of those 57 cases of pulmonary cryptococcosis, diagnosed in non-AIDS patients. Results The mean age in pulmonary cryptococcosis was 53.2 years, the male and female ratio was 1:1.1. Immunocompromised patients were 30 cases, immunocompetent host were 23 cases and 3 cases had underlying disease but in normal immunity condition and in 1 case the underlying condition was not known. The most common clinical symptom was cough, in 28 cases (49.1%). Asymptomatic was the next, 14 cases (12.3%). Pulmonary cryptococcosis were frequently misdiagnosed initially as pulmonary tuberculosis or lung cancer, because most patients had nonspecic clinical symptoms and frequent radiological ndings were pulmonary nodules. Most of the patients were diagnosed by histology, and the tissue was taken through the percutaneous needle aspiration or biopsy in 34 cases (the most common, 59.5% of the patients) and operation in 15 cases (26.3%). The main antifungal agents used in this study were uconazole. The clinical outcome was depended on the patients immunities, and most of them had good prognosis. Conclusion Most of the non-AIDS patients with pulmonary cryptococcosis had nonspecic symptoms. The most common radiologic ndings were pulmonary nodule or nodules. Pulmonary tuberculosis or lung cancer, which means that histologic diagnostic procedure is mandatory in most cases for the accurate diagnosis. The clinical results were good in most of the patients with uconazole single therapy, irrespective of immune status of the patients.

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SCHISTOSOMIASIS WITH CRYPTOCOCCUS, PRESENTING AS PULMONARY NODULE IN A 62 YEAR OLD WOMAN: CASE REPORT NINO JESSIELITO DOYDORA, IMELDA MANUEL, EDZEL TAMAYO, JUN PALER, NOEL ESTRELLA Department of Internal Medicine, Section of Pulmonology, University of Perpetual Help DALTA Medical Center, Las Pinas, Philippines Introduction Schistosomiasis affects >207 million people worldwide and is 2nd most prevalent tropical disease, next to malaria. Cryptococcus sp. is fungus that causes CNS/pulmonary disease. This report aims to describe a case of a dual infection by Schistosoma and Cryptococcus, presenting as a solitary pulmonary nodule. Methods A 62 years old female, hypertensive, non-diabetic, 28 pack year smoker, known with COPD was admitted due to a solitary pulmonary nodule on her chest x-ray. No cough, no dyspnea, no anorexia nor weight loss noted. CT scan revealed a speculated pulmonary nodule, left. CT scan guided biopsy was done, which revealed few atypical cells. Primary consideration was pulmonary mass probably malignant. She was previously diagnosed with gastrointestinal tuberculosis last 2007 after undergoing cholecystectomy; and histopathology revealed chronic granulation of the omentum omentitis consistent with tuberculosis; was given a 4 drug regimen for 9 months. After securing a cardio-pulmonary clearance, she had upper lobe lobectomy, left lung. Intraoperative ndings revealed a 3 3 cm pulmonary nodule. Histopathology revealed chronic granulomatous inammation with foreign body giant cell reaction secondary to parasitic ova compatible with schistosomiasis with superimposed fungal infection probably Cryptococcus spp. Immunochemical staining (periodic-acid Schiff, mucicarmine, silver methanamine) revealed ndings compatible with Cyrptoccocus spp. Patient was treated with praziquantel for schistosomiasis and uconazole for cryptocococcis. Results Pulmonary schistosomiasis usually follows hepatic colonization, pulmonary cryptococcosis is usually found with CNS disease. Patient was asymptomatic; thus, she was exposed to a lower inoculum load of the Schistosoma and had cryptococcus colonization rather than infection. Being a smoker with a solitary speculated nodule and tissue biopsy by FNAB of atypical cells, bronchogenic CA was highly considered. But biopsy showed schistosomiasis with cryptococcosis. Conclusion Bronchogenic carcinoma was the initial impression in our patient but was schistosomiasis w/cryptococcosis by biopsy. No local data has reported a case of a malignant looking pulmonary nodule that turned out to be a dual infection of Schistosoma and cryptococcus. Therefore, a solitary, malignant-looking pulmonary nodule may not be malignant and should require histopathologic conrmation.

DO WE REALLY HAVE TO TREAT PATIENTS WITH NTM PULMONARY DISEASES? YUICHI FUKUDA, NOBUYUKI ASHIZAWA, NAOKI IWANAGA, KOICHI IZUMIKAWA, MASAFUMI SEKI, HIROSHI KAKEYA, YOSHIHIRO YAMAMOTO, KATSUNORI YANAGIHARA, HIROSHI SODA, SHIGERU KOHNO Respiratory Medicine, Sasebo City General Hospital, 9-3 Hirase machi, Sasebo city, Nagasaki prefecture, Japan Introduction The number of patients with Nontuberculous mycobacteria (NTM) pulmonary disease is increasing rapidly in Nagasaki, Japan. Although the American Thoracic Society (ATS) Guideline recommends long time treatment, it is difcult for patients to pay for the medication and sometimes they are suffered from serious adverse effects. To evaluate the effects of the treatment we examined the correlation between the treatment with or without antibiotics and the clinical outcome of the patients with NTM pulmonary diseases. Methods We investigated 58 patients with NTM pulmonary diseases who were diagnosed based on ATS Guideline from April 2008March 2009 in Sasebo City General Hospital, retrospectively. The clinical outcome was evaluated at the last visit to our hospital after at least 6 months follow-up period as improved, persistence and worsened. Results A total of 47 patients were subjected for analysis. Overall results showed, 13 (28%), 32 (68%) and 2 (4%) patients were evaluated as improved, persistence and worsened. Furthermore, among the 47 patients, 17 patients were treated with more than 2 antibiotics including clarithromycin, 7 patients were treated with clarithromycin alone because of the visual disorder or other problems, and 23 patients were not treated with any antibiotics. The average age of these three groups were 78.7, 76.3 and 72.8, respectively. The improved rates of these three groups were, 58.8, 42.9 and 0%, respectively. Interestingly, the persistence rates of these three groups were, 29.4, 57.1 and 100%, respectively. Moreover, none of the patients without any antibiotics treatment got worsened during our observation period. Conclusion Our result showed that the persistent rates were high regardless of the treatment. Furthermore, more than 2 antibiotics are necessary to obtain the high efcacy of the treatment. We may have to select patients carefully to initiate the antibiotics therapy to treat NTM pulmonary diseases.

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THE EFFECT OF DIAPHRAGMATIC LENGTH ON TRANSDIAPHRAGMATIC PRESSURE ZEGUANG ZHENG, ANDREA ALIVERTI, ANTONELLA LO MAURO, DARIO BOVIO, EMANUELA ZANNIN, RONGCHANG CHEN, NANSHAN ZHONG, PETER T MACKLEM Respiratory Medicine, The State Key Laboratory of Respiratory Disease, Yanjiang, Guangzhou, PR China Introduction Skeletal muscle produces the maximal force at its optimal length during isometric contraction. As for other skeletal muscles, diaphragm follows similar force-length and force-stimulation (central drive) relationships. In this study, we wanted to investigate the effect of diaphragmatic length on transdiaphragmatic pressure at controlled levels of diaphragmatic activation. Methods We measure abdominal displacement (Vab) by optoelectronic plethysmography (OEP) as an index of diaphragm length (Ldi), diaphragm electromyography (Edi) as an index of diaphragm neural activation and transdiaphragmatic pressure (Pdi) as an index of diaphragmatic force. Edi at active TLC was taken as maximal Edi (Edi,max). Three adults were recruited to perform a series of Meuller maneuvers gradually increasing Pdi at different values of Vab (Ldi) from RV to TLC while attempting to keep Vab constant during the maneuver. Pdi-Ldi curves were constructed at 0, 5, 10, 20, 30, 40, 50, 60 and 70% Edi,max. Results Our results showed that: a) the optimal length of the diaphragm was similar, ranging from 0.5 liters below FRC to 0.3 liters below FRC at different neural activation (from 0 to 70% Edi,max). b) Pdi-Ldi relationships had a positive slope for Ldi higher than optimal, and had a negative slope for Ldi lower than optimal (see graph).

COMPARISON OF RESPIRATORY PARAMETERS AND PLASMA CYTOKINE LEVELS BETWEEN THE TREATMENTS OF FLUTICASONE/SALMETEROL AND IPRATROPIUM/ TERBUTALINE/BUDESONIDE IN MECHANICALLY VENTILATED COPD PATIENTS HUANG-PIN WU1,2, WEN-BIN SHIEH1,2, SHI-CHUAN LIN2, MING-YI CHIEN2, FANG-CHUN LIAO2, SHU-CHUAN CHANG2, YU-CHIH LIU1,2 1 Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital at Keelung, Chang Gung University College of Medicine, Taoyuan, Taiwan, and 2Department of Respiratory Therapy, Chang Gung Memorial Hospital at Keelung, Taiwan Introduction It is unknown whether the bronchodilation and anti-inammatory effects of inhaled salmeterol and uticasone were better than that of traditionally inhaled ipratropium, terbutaline and budesonide in mechanically ventilated chronic obstructive pulmonary disease (COPD) patients. Methods Nineteen stable COPD patients with respiratory failure were randomly enrolled into two groups. Patients in the SF group were treated with inhaled salmeterol and uticasone delivered by a metered-dose inhaler (MDI) with a spacer and patients in the ITB group were treated with inhaled nebulized ipratropium, terbutaline and budesonide. Results There were no signicant differences in minute ventilation, intrinsic positive end expiratory pressure, airway resistance, and rapid shallow index between the ITB and SF groups from day 1 to day 7. There were no differences in plasma interleukin (IL)-6, IL-10, IL-12, and transforming growth factor-beta1 levels between day 1 and day 7 in the ITB or SF group. Conclusion Based on the most cost-effective treatment, salmeterol and uticasone given by an MDI with a spacer should be considered rst in mechanically ventilated COPD patients in this preliminary study.

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IN-HOSPITAL MORTALITY OF COPD PATIENTS IN ACUTE EXACERBATION ADMITTED AT USTH FROM JANUARY 2007 TO DECEMBER 2008 APOLONIO JAVIER JR, ISAIAS LANZONA, RIA ARLINA CALATA-ROSALES Center for Respiratory Medicine, University of Santo Tomas Hospital, Manila, Philippines Introduction Studies on acute exacerbation of COPD have attempted to identify various risk factors for in-hospital mortality. These predictors, when properly identied, will assist clinicians in identifying subsets of patients with acute exacerbations of COPD that are at higher risk of in-hospital mortality and help them in making decisions of instituting intensive care management in patients with acute exacerbations of COPD in order to allow better utilization of medical resources. Hence, this study will determine in-hospital mortality of COPD patients admitted for an acute exacerbation at USTH and to identify independent risk factors that inuence in-hospital mortality. Methods Patients were included for analysis if they were admitted at the University of Santo Tomas Hospital, Private Division, over a 2-year period between January 2007 and December 2008, with the primary diagnosis of COPD in acute exacerbation or acute respiratory failure secondary to COPD using the Center for Respiratory Medicine Census and Database. Epidemiologic and baseline, admission laboratory data were tabulated. The primary outcome studied was in-hospital mortality. The length of hospital stay was the secondary outcome of this study. Results A total of 160 patients were admitted with the diagnosis of COPD in acute exacerbation from January 2007 to December 2008 at the UST Hospital private division and were considered for analysis. Majority of the patients (91.2%) are discharged from the hospital while 8.8% expired during their course of stay. Comparison of the demographic characteristics, presence of comorbid conditions, smoking status between the surviving and non-surviving patients showed no signicant difference among the variables except for the presence of cancer. The need for mechanical ventilation on admission was signicant between the two groups (p = 0.0001). The median length of stay was 6 days on surviving/discharged patients while 13 days for those who expired but it was not statistically signicant. Statistically signicant increases in mortality were seen only in patients who have lung cancer and who required mechanical ventilation with p value of 0.003 and 0.001 respectively. Conclusion In-hospital mortality of patients with acute exacerbation of COPD is 8.8%. Among the variables, cancer and mechanical ventilation are identied as independent risk factors for in-hospital mortality.

Conclusion We conclude that the ability of the diaphragm to develop force is maximal below FRC.

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THE OCCURRENCE OF METABOLIC SYNDROME AND ITS COMPONENTS IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) VK VIJAYAN, S BANSAL, R CAROLI, N GOEL Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India Introduction COPD has been reported to be associated with systemic inammation leading to extrapulmonary morbidity and mortality (1). As systemic inammation is a characteristic feature of metabolic syndrome (presence of abdominal obesity, atherogenic dyslipidemia, raised blood pressure and raised insulin resistance) (2), we undertook a study to know the occurrence of metabolic syndrome and its components in COPD patients. Methods 28 COPD patients and 14 age and sex matched control subjects were included in the study. The body mass index (BMI) was calculated in both groups as kg/m2. The criteria for the identication of the metabolic syndrome as per the Adult Treatment Panel III included three or more of the following features: central obesity (>102 cm in men, > 88 cm in women), triglyceride levels (>150/dl), high-density lipoprotein (HDL) levels (<40 mg/dl in men, < 50 mg/dl in women), blood pressure (>130/>85 mm Hg), fasting blood sugar levels (>100 mg/dl) (2). Values >2.5 Homeostasis Model Assessments (HOMAIR) units were considered as insulin resistance (3). Results The prevalence of metabolic syndrome as per the Adult Treatment Panel III was similar in both the COPD (7.1%) and control (7.1%) subjects. The body mass index of COPD vs control group was 20.7 + 4.2 kg/m2 and 23.9 4.2 kg/m2 respectively (p = 0.03). On comparison of COPD with healthy control subjects, central obesity in 3.6% vs 28.6%, raised triglyceride in 25% vs 7.1%, low HDL in 46.4 vs 50%, raised blood pressure in 25% vs 0%, impaired fasting glucose in 25% vs 14.2%, and insulin resistance in 71.7% vs 35.4% respectively were observed. The mean value of insulin resistance in HOMA-IR units was higher in COPD compared to the control subjects (6.5 + 5.6 vs 3.0 + 2.9, p < 0.02). Conclusion Though the prevalence of metabolic syndrome is same in both groups, the proportion of subjects with high insulin resistance, high triglycerides, high blood pressure and impaired fasting glucose is higher in COPD patients compared to healthy control subjects, despite the fact that the COPD patients have signicantly lower BMI. References 1. Watz H, Waschki B, Kirsten A, et al. The metabolic syndrome in patients with chronic bronchitis and COPD: frequency and associated consequences for systemic inammation and physical inactivity. Chest 2009; 136: 103946. 2. Grundy SM, Brewer HB Jr, Cleeman JI, et al. Denition of metabolic syndrome: report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientic issues related to denition. Arterioscler Thromb Vasc Biol 2004; 24: e138. 3. McAuley KA, Williams SM, Mann JI, et al. Diagnosing insulin resistance in the general population. Diabetes Care 2001; 24: 4604.

AUTONOMIC DYSFUNCTION IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE SK CHHABRA, M GUPTA, V BANSAL Cardio-Respiratory Physiology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India Introduction Autonomic dysfunction has been implicated in the pathophysiology of Chronic Obstructive Pulmonary Disease (COPD) and may underlie cardiac complications. Heart Rate Variability (HRV), reecting sympatheticparasympathetic balance; and post-exercise Heart Rate Recovery (HRR), reecting parasympathetic response, are simple, precise and well-standardized tools to assess autonomic imbalance. The study was conducted to investigate the autonomic dysfunction in COPD. Methods Thirty nine stable and normoxaemic male COPD patients [GOLD stages: mild (n = 10), moderate (n = 17) and severe (n = 12)] and 11 healthy non-smoker male controls were included in this cross-sectional study. After baseline evaluation, continuous ECG record was obtained at rest and standardized HRV analysis1 was performed to obtain time domain (average heart rate, SDNN, RMSSD, pNN50) and frequency domain indices (HF nu, LF nu and LF/HF ratio). Post-exercise HRR2 was calculated for an incremental submaximal cycle ergometry. Abnormal HRR was dened as a recovery of <12 beats in the rst minute post-exercise. The two groups were compared and the inter-relationships between autonomic function and clinico-physiological parameters were examined. Results The chronotropic response index [CRI = (peak heart rate resting heart rate)/((220 age) resting heart rate)] was signicantly less in patients (p < 0.01). The time domain indices were similar in two groups. Among the frequency domain parameters; HF nu was higher, while LF nu and LF/HF ratio were signicantly decreased in patients (p < 0.05). There was no correlation between HRV parameters and severity of the disease. The post exercise HRR response was blunted in majority of patients with a negative correlation with age, pack-years of smoking and BODE index; and positive correlation with diffusion capacity (DLCO and KCO) (p < 0.05). Conclusion Our observations suggest that at rest, there is a parasympathetic dominance in stable, normoxaemic COPD patients. However, after exercise, the parasympathetic recovery is blunted that correlates with severity of the disease. As the normal autonomic response to exercise is sympathetic stimulation, we hypothesize that it may exaggerate in COPD patients, blunting the post-exercise recovery due to parasympathetic response. References 1. Heart rate variability: standards of measurement, physiological interpretation and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Circulation 1996; 93: 104365. 2. Lacasse M, Franois Maltais, Paul Poirier, et al. Post-exercise heart rate recovery and mortality in chronic obstructive pulmonary disease. Respir Med 2005; 99: 8776.

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A PILOT STUDY ON DOMICILIARY PULMONARY REHABILITATION PROGRAM IN THE MANAGEMENT OF SEVERE COPD GIRISH SINDHWANI1, ANJU VERMA2, DEBASIS BISWAS3, MALINI SRIVASTAVA4, JAGDISH RAWAT1 1 Department of Pulmonary Medicine, 2Department of Physiotherapy, 3 Department of Microbiology, 4Department of Psychology, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Dehradun, Uttarakhand, India Introduction The Himalayan region of Northern India suffers from a huge burden of COPD, which has a far-reaching impact on the health status and economy of the region. Along with conventional medical management, a signicant proportion of COPD patients need rehabilitation owing to the systemic effects of this pulmonary disease. Pulmonary Rehabilitation, which is conventionally administered in an institutional setting, is often difcult to implement in resource-poor settings, owing to the high cost involved and the requirement of extensive infrastructure. To bridge this gap, we designed a domiciliary pulmonary rehabilitation program (DPR) and evaluated its usefulness in the management of severe COPD. Methods Twenty male patients suffering from severe COPD (10 patients each in experimental and control groups) were enrolled from out-patients attending the Pulmonary Medicine Department of Himalayan Institute of Medical Sciences, a tertiary care center in the Himalayan region of Northern India. The experimental group was subjected to DPR along with medical management. Patients in this group participated in monthly sessions of the program. Each session comprised of training in respiratory exercises by a trained respiratory physiotherapist, dietary counseling and consultation for psycho-social support. Patients were instructed to do a set of physical exercises at home till next monthly visit. The control group underwent conventional medical management only. During each monthly visit, subjects in both the groups were assessed for quality of life and exercise capacity with the help of Clinical COPD Questionnaire (CCQ) scores, 6 minutes walk distance (6MWD) and spirometry values (FEV1 and FVC). Results Demographic and baseline respiratory parameters in both groups were comparable. Statistically signicant difference was observed between the two groups in CCQ scores from the fourth month onwards (p = 0.002 & < 0.001 at end of 4 and 6 months respectively). 6MWD results also showed a similar trend (p = 0.009 and 0.001 at the end of 4 and 6 months respectively). No signicant difference was observed in any of the spirometry values. Conclusion Inclusion of this DPR program in the management of patients with severe COPD could help improve their quality of life and exercise endurance, and therefore act as a substitute for conventional PR in resource-limited situations.

CORRELATION BETWEEN INTERLEUKIN-8 LEVELS IN INDUCED SPUTUM WITH THE DEGREE OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) SEVERITY GANIS TJAHJONO, GANIS GANIS, DANIEL MARANATHA, LAKSMI WULANDARI, SLAMET HARIADI, YUSUF WIBISONO Department of Pulmonology, Dr. Soetomo General Hospital, Surabaya, Indonesia Introduction There is signicant neutrophilic inammation in COPD patients which can be detected by increased interleukin-8 (IL-8) in induced sputum. Whether the increase in IL-8 level correlate with the degree of COPD severity are still to be determined. Methods Thirty eight patients with stable COPD in Pulmonology Outpatient Clinic Dr. Soetomo General Hospital were enrolled to this study. Pulmonary function test were done to determine the disease severity according to GOLD classication. Induced sputum were done according to standard method, and measured for IL-8 level. Correlation of IL-8 levels and the degree of COPD severity were analyzed with Spearman test. Results According to GOLD classication, 1 patient was regarded as mild, while 16, 17, and 4 patients was regarded as moderate, severe, and very severe disease, respectively. Patient with mild disease was then excluded from the analysis because there is evident of bacterial infection from purulent sputum. There is a trend of increasing IL-8 level in induced sputum with increasing degree of COPD severity, being 129 107.45 pg/mL, 158 91.53 pg/mL, 174 109.41 pg/mL in moderate, severe, and very severe disease, respectively. Anyhow, statistical analysis showed no signicant correlation between IL-8 level and the degree of COPD severity (r = 0.345, p > 0.05). Conclusion There is no correlation between IL-8 levels in induced sputum with the degree of COPD severity, although there is a trend of increasing IL-8 levels with increasing degree of the disease severity. Contribution of subclinical infection or other factors may confound the results. There might be other more important cytokines be responsible such as LTB4, TNF-.

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EFFECT OF PULMONARY REHABILITATION ON MATRIX METALLOPROTEINASE-9, TISSUE INHIBITOR OF METALLOPROTEINASE-1, MIDTHIGH MUSCLE CROSSSECTION AREA, SIX MINUTE WALK DISTANCE IN PATIENTS WITH COPD BALAKRISHNAN MENON, SENTHIL KUMAR, VISHAL BANSAL, VK VIJAYAN Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India Introduction The presence of systemic inammation is well documented in COPD. However the effect of pulmonary rehabilitation on systemic inammatory markers have not been fully evaluated. We evaluated the effect of pulmonary rehabilitation on Matrix Metalloproteinase-9 (MMP-9), Tissue Inhibitor of Metalloproteinase-1T (IMP-1) [markers of inammation], along with Midthigh muscle Cross-Section area (MTCSACT) [marker of muscle mass] and Six Minute Walk Distance (6MWD) [marker of exercise capacity] in COPD patients. Methods 31 stable moderate to severe COPD patients as per GOLD guidelines were randomly allocated to two groups after run-in period. Group 1 (n = 15) was given inhaled tiotropium and formoterol for 8 weeks while group 2 (n = 16) received pulmonary rehabilitation in addition to inhaled therapy for 8 weeks. Results The value of MMP-9 decreased signicantly after inhaled medications in both the groups (Group 1 mean change was 171.47 ng/ml and in group 2 was 328.91 ng/ml [p < 0.05]). However there was no signicant change in MMP-9 after rehabilitation mean 10.2 ng/ml (p > 0.05). The levels of TIMP-1 showed signicant increase after inhaled medications. Mean change was 10.8 ng/ml in group 1 and 21.38 ng/ml in group 2 (p > 0.05). There was no signicant change in TIMP-1 value after rehabilitation 17.94 ng/ml (p > 0.05). The value of MTCSACT did not change signicantly with inhaled medications. The mean change in group 1 was 1.0 cm2 (p > 0.05) and in group 2 was 2.32 cm2 (p > 0.05). However there was signicant change in MTCSACT after rehabilitation (3.83 cm2 [p = 0.011]). The mean 6MWD was seen to improve signicantly after inhaled medications in both the groups. The mean change in group 1 was 56.81 m (p < 0.05) and in group 2 was 46.69 m (p < 0.05). Highly signicant further increase in 6MWD was seen after rehabilitation 47.3 m (p = 0.006). Conclusion There was signicant decrease of pro inammatory MMP-9 and increase in anti-inammatory TIMP-1 after inhaled therapy. Pulmonary rehabilitation did not signicantly affect these parameters. 6MWD showed signicant increase with inhaled therapy and further signicant improvement with pulmonary rehabilitation. MTCSACT was not affected with inhaled medications but showed signicant improvement with pulmonary rehabilitation.

FIBRINOGEN LEVEL AND METABOLIC SYNDROMES RISK FACTORS IN STABLE CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENTS YUNITA ARLINY, FAISAL YUNUS, WIWIEN H WIYONO Persahabatan Hospital, Jakarta, Indonesia Introduction The metabolic syndrome is a condition frequently found among individuals >60 years of age. Systemic inammation is relevant extrapulmonary markers of morbidity and mortality in patients with COPD. The metabolic syndrome represents a cluster of risk factors (abdominal obesity, atherogenic dyslipidemia, hypertension, and insulin resistance). Fibrinogen was one of the acute phase protein that can use as marker of systemic inammation and metabolic syndrome. This study was undertaken to evaluate the relationship between brinogen level and metabolic syndromes risk factor in stable COPD patients. Methods Observasional cross sectional study, twenty-fth stable COPD patients we measured the characteristic of metabolic syndrome and plasma brinogen levels. The criteria for identication of metabolic syndrome include 3 or more of the following features: abdominal obesity (waist circumference 90 cm in men, 80 cm in women), triglycerides 150 mg/dl, high density lipoprotein cholesterol (HDL) <40 mg/dl in men and <50 mg/dl in women, blood pressure 130/85 mmHg, and fasting glucose levels 110 mg/dl. Data collected between AprilMay 2010 in Persahabatan Hospital. Results The sample were 24 stable COPD patients. The mean of age in stable COPD patients was 63.38 5.84 years, FEV1 51.17 13.03% predicted. Fibrinogen level was increased (mean 369.13 72.56 mg/dl. All samples from stable COPD patients had at least one of metabolic syndrome risk factor. Conrmed metabolic syndrome presence in 54.16% stable COPD patients. The frequencies of metabolic syndrome in stable COPD patients GOLD II and III were 38.46%, 61.54% and not presence in GOLD IV patients. Conclusion Study found that brinogen level was increased in stable COPD patients and more than one-half of the stable COPD patients had coexisting with metabolic syndrome with more frequent in severe COPD patients.

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USE OF SIX-MINUTE WALK TEST IN DEFINING INTENSITY DURING TREADMILL TRAINING IN PATIENTS WITH COPD RITESH SINGH, DEEPAK TALWAR, DEEPAK PABREJA, POOJA SATIJA Metro Centre for Respiratory Diseases, Metro Multispeciality Hospital, L-94, Sec.-11, Noida, India Introduction Treadmill training intensity for patients with COPD is normally based on an incremental exercise testing. The six-minute walk test (6MWT) has been proposed as an alternative to an incremental exercise test for this purpose. The aim of this study was to measure the physiological responses to constant load treadmill exercise performed at an intensity of 60% VO2peak determined from the 6MWT in stable COPD. Methods 35 patients with stable COPD (GOLD stage I to IV) were prospectively analyzed. Subjects with co-morbidities limiting exercise performance were excluded. The better of two 6MWT was used to calculate VO2peak for treadmill exercise using regression equation. After 30 minutes rest, subjects performed constant-load treadmill exercise at 60% of the calculated VO2peak. During all exercise, cardiorespiratory variables were recorded. The heart rate reserve measured at the end of treadmill exercise (HRRtet) was compared to peak HRR of the 6MWT (HRRwalk). Results Of 35 patients 24 (68.6%) were male and mean age 55.55 14.56 years. A signicant correlation was observed between HRRtet and HRRwalk (r = 0.807; p 0.001). Heart Rate (r = 0.88; p-value < 0.001), Respiratory Rate (r = 0.93; p-value < 0.001), SpO2 (r = 0.96; p-value < 0.001) and Dyspnoea on Borg scale (r = 0.73; p-value = 0.005) were also signicantly correlated during 6MWT and prescribed treadmill exercise. The training VO2 was correlated signicantly with heart rate (r = 0.56; p 0.001), heart rate reserve (r = 0.36; p = 0.016), SpO2 (r = 0.42; p = 0.005) and dyspnoea (r = 0.35; p = 0.02) during treadmill training. The %HRR (HRRtet/HRRwalk) was 83.6 36.2% in response to prescribed training intensity. ANOVA with post hoc Bonferroni correction showed that SpO2 (p = 0.005) and heart rate (p = 0.0001) during training were signicantly affected by severity of COPD. Conclusion VO2peak derived from 6MWT can be used for prescribing Treadmill training intensity in COPD patients.

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COMPARISON OF TESTOSTERONE AND GROWTH HORMONE IN STABLE CHRONIC OBSTRUCTIVE PULMONARY PATIENTS: A CASE CONTROL STUDY MUHAMMAD FACHRI, FAISAL YUNUS, WIWIEN H WIYONO, ARIA KEKALIH Depatemen Pulmonologi dan Ilmu Kedokteran Respirasi RS Pesahabatan Jl. Persahabatan Raya No 1 Jakarta Timur, Indonesia Introduction There is a correlation between the disturbance of endocrine glands and muscular weakness in COPD patients. Two hormones assumed to be affected are growth hormone and testosterone hormone. Methods In Observational case control study, we collected data consecutively from stable COPD patients group and healthy people group. Data was collected during June 2009-July 2010 in Persahabatan Hospital. We examined IGF-I and testosterone using ELISA test. Results There were 28 stable COPD patients as case group and 28 normal subjects as control. The characteristic of age, sex and body mass index between groups were comparable. Testosterone hormone level median in stable COPD patients was 506.5 (1701600) ng/dL and relatively higher than in the control group: 465 (2102010) ng/dL. IGF-I level mean in stable COPD was 98.13 27.27 ng/mL and relatively lower than in control group: 146.5 34.2 ng/mL. However, the differences were not statistically signicant. Conclusion Previous studies have found a decreasing trend of growth hormone/IGF-1 and increasing testosterone level in male COPD patients compared to healthy person of the same age, though the differences were insignicant. This study supports the evidence that changes of growth hormone and testosterone in male COPD patients is not relevant, nevertheless the controversy remains.

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HELPING PEOPLE STAY HEALTHY: A PILOT OF NURSE CLINIC FOR COPD PATIENTS IN HONG KONG SHU WAH NG, WAI YI TSANG, CHUNG LEUNG POON, YUK YIN CHONG, KIT CHING TSE, SIU KEUNG TANG, YUET KWAI CHAN, VERONICA LEE CHAN, CHUNG MING CHU United Christian Hospital, Kwun Tong, KLN, Hong Kong, China Introduction Chronic Obstructive Pulmonary Disease (COPD) was ranked second as a respiratory cause of hospitalization (14.6%) and inpatient beddays (20.5%) among common respiratory diseases in Hong Kong. The data was consistent in a local district hospital. In line with the Hospital Authoritys service plan of managing growing demand, a pilot of Nurse Clinic for COPD was established in December 2009. It focused on prevention, early detection and prompt intervention to reduce the need for intensive medical care. This half-year review aims to evaluate the effectiveness of the Nurse Clinic on reducing these patients avoidable healthcare utilization. Methods The Nurse Clinic for COPD was established in December 2009. Conrmed COPD patients who were hospitalized could be recruited. Respiratory Nurse provided COPD care according to an approved protocol. Firstly, there was a system for creating, validating and updating a register of COPD patients in order to systematically and proactively manage their care. Secondly, a COPD care program was conducted, included assessment & monitoring, risk factor reduction, stable COPD care and exacerbation COPD care. Besides, patients were empowered with the required knowledge and skills for self-care management of COPD. Moreover, a 24-hour hotline was available for improving COPD patients health access. Results There were 65 COPD patients recruited between December 2009 and June 2010. All were analyzed for their healthcare utilization in three months before and after joining the clinic respectively. Their mean age was 74.8 6.85 and nearly all of them were male. More than 90% of them were Severe or Very Severe COPD. Also, 83.1% was ex-heavy smoker and 15.4% was current smoker. It was statistically signicant showing that the number of emergency department attendance was reduced by 42% from 2.4 to 1.4 times (p < 0.001). Also, the total numbers of unplanned admission and the length of stay were reduced by 44.5% from 1.91 to 1.06 (p < 0.001) times and 49.5% from 5.5 to 2.78 days (p = 0.001) respectively. Conclusion The healthcare utilization of the COPD patients was signicantly reduced after they were under the care of Nurse Clinic, included emergency department attendance, and number and length of stay of unplanned admission. More outcome indicators will be evaluated in one-year review such as Quality of Life and Modied Borg Scale.

PROTEOMIC ANALYSIS OF SPUTUM IN PATIENTS WITH COPD AND COPD EXACERBATIONS SOO-TAEK UH, YANG KI KIM, KI UP KIM, SUNG WOO PARK, DO JIN KIM, AN SOO JANG, CHOON SIK PARK, YONG HOON KIM Soon Chun Hyang University Hospital, 22 Daesakwan-Gil, Yongsan-Ku, Seoul, Korea Introduction An acute exacerbation of chronic obstructive pulmonary disease (AECOPD) signicantly impacts on the deterioration lung function, economy burden, and mental status. Most studies were focused on the serum even though the disease of COPD is conned on the airway and lung. This study was performed to nd biological marker in the early diagnosis of AECOPD and to know the underlying mechanisms of AECOPD by comparing proteome-based analysis of sputum. Methods Sputa were obtained from eight patients with AECOPD during hospitalization and then 6 weeks later after acute exacerbation. The sputa were analyzed using 2-DE in gel electrophoresis. And spot differences were quantied and expressed spots were identied by LC-MS. Results Total 503 spots were identied. 20 spots in AECOPD showing more than two-fold increase compared to those stable COPD (rst group) and 29 spots in stable COPD showing more than two-fold increase in AECOPD (second group) were analyzed by LC-MS. Among rst group, calpain-like protease CAPN10b, brinogen gamma chain, transferrin, Cyclophilin B, and myosin-9 were promising proteins associated with AECOPD. Among second group, lactoferrin, plectin, proapolipoprotein, and actin binding protein were promising proteins preventing AECOPD. Conclusion The analysis of sputum from patients with stable COPD and AECOD could identify the biomarker of AECOPD, but validation studies are needed to identify above hypothesis.

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CURRENT STATUS OF THE USE OF DRUGS WITHOUT AUTHORIZATION BY STATE FOOD AND DRUG ADMINISTRATION OF CHINA IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN SOUTHWEST CHINESE CITY OF CHONGQING AND THE EVALUATION OF INTERFERENCE EFFECT GUO-QIANG CAO1, JING LI1, LIAN LI2, HAI-DONG LI3, HENG-YI CHEN1, FANG-WEN WANG1, HU-CHENG WANG1 1 Department of Respiratory Medicine; Institute of Surgery Research, Daping Hospital; Third Military Medical University, Chongqing, China, 2Jiangjin People Hospital, Guangdong, China, and 3No. 324 Hospital of Chengdu Military Command, Chongqing, China Introduction We sought to investigate Current status of the use of drugs without authorization by State Food and Drug Administration of China (DWAS) in patients with COPD in southwest Chinese city of Chongqing and the evaluation of interference effect. Methods From October 2009 through December 2010,656 hospitalized COPD patients were included in this study, 82 patents have been treated with DWAS. Performance liquid chromatography was performed to detect whether DWAS contains corticosteroid. Preprandial blood glucose and plasma cortisol concentrations (8:00, 16:00 and 24:00) were measured. The intervention consisted of patients and watchers getting health education at intervals, a telephone call and out-patient follow up monthly, home visits trimonthly. Results Primary education/illiteracy rate in DWAS patients was signicantly higher than in control group (P < 0.01). In the past one year, the frequency of acute exacerbation COPD (AECOPD) in the control group was signicantly less than in the DWAS group. Furthermore, the proportion of patients with AECOPD in DWAS group was 3 times more than the control group (2 = 4.23, p < 0.05). 41% of patients buying DWAS because of its lower price than regular medicines. Our study revealed that 1.0 g DWAS contained 5.05 mg prednisone acetate. The number of patients with cortisol levels below normal range in DWAS group was signicantly more than that of the control group (2 = 34.89, p < 0.01). Medical education, telephone follow-up and community intervention can signicantly reduce the risk of the DWAS patients taking it again. Conclusion COPD patients in southwest Chinese city of Chongqing there was a certain proportion of patients being administered DWAS. Lower socioeconomic status and lower level of education is closely related with the taking of DWAS. Long-term use of these drugs not only affect disease control, but will lead to hyperglycemia (or diabetes) and hypertension. Medics interventions can reduce the risk of DWAS being.

QUANTITATIVE ASSESSMENT OF PULMONARY REHABILITATION BY USING OF IMPULSE OSCILLOMETRY MASANORI YOKOBA, MAYUKO WADA, MASARU KUBOTA, KEN KATONO, AKIRA TAKAKURA, NOBUAKI HAMAZAKI, TOMOTAKA KOIKE, NORIYUKI MASUDA, MASATO KATAGIRI Respiratory Medicine, Kitasato University, Kitasato 1-15-1, Minami-ku, Sagamihara-shi, Kanagawa, Japan Introduction Pulmonary rehabilitation exercise program includes not only endurance and strength training, but also conditioning of the chest wall. Pulmonary rehabilitation improve exercise tolerance and ability to engage in activities. However, it does not improve parameters of traditional pulmonary function tests directly (i.e. FEV1.0%). The aim of this study is assess the relationship between pulmonary rehabilitation and alteration of respiratory resistance (R), respiratory impedance (Z), reactance (X) and elasticity of lung and thorax (Ers) by using new impulse oscillometry system (IOS). Methods Five COPD patients recruited for this study (M : F = 4:1) who did not start to treat with Tiotropium during study. We analyzed 1) rating of perceived exertion (Borg score) for breathing, 2) lower limb muscle strength by myodynamometer (Tas F-1: Anima Corp, Tokyo, Japan) and 6 minutes walking distance (6MWD) and 3) central respiratory resistance (R20), peripheral respiratory resistance (R5-20), total respiratory resistance (R5), respiratory impedance (Z5), distal capacitive reactance (X5) and elasticity of lung and thorax (Ers) evaluated quantitatively by using MasterScreen impulse oscillometry system (MS-IOS: VIASYS Healthcare, Hchberg, Germany), before and after pulmonary rehabilitation exercise program. Results Mean period of pulmonary rehabilitation exercise program was 71 days. After the rehabilitation program, BORG score for breathing was decreased, and mean lower limb muscle strength and 6MWD were increased signicantly. In contrast, mean values of R20, R5-20, R5, Z5, X5 and Ers were not changed signicantly. Conclusion Exercise tolerance improvement related with pulmonary rehabilitation program may not be assess by IOS, as same as traditional pulmonary function tests.

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EFFICACY AND SAFETY OF SINGLE-DOSE 2.0 G OF AZITHROMYCIN (ZSR) FOR ACUTE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) NOBUHIRO ASAI, YOSHIHIRO OHKUNI, AKINA KOMATSU, RYO MATSUNUMA, KEI NAKASHIMA, KATSUTOSHI ANDO, TAKUYA IWASAKI, MASAFUMI MISAWA, NORIHIRO KANEKO Respiratory Medicine, Kameda Medical Center, Kamogawa City, Chiba, Japan Introduction COPD, the fourth leading cause of death in the world is expected to be the third by the year 2020 and the medical cost for COPD is expected to increase year by year everywhere. Acute exacerbation of COPD is the major cause of morbidity and mortality for COPD patients. Methods To evaluate the efcacy and safety of ZSR for acute exacerbation of COPD, we retrospectively reviewed all the patients with acute exacerbation of COPD who were treated by ZSR. Patients who need mechanical ventilation were excluded in this study. In comparison with patients who received parenteral therapy for COPD exacerbation, clinical cure rate, the length of stay in hospital, medical cost were evaluated. Results Nine patients 8 male and 1 female were evaluated. COPD stage of I/II/III/IV unknown = 2/1/3/1/2 were classied based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Clinical cure rates of ZSR and parenteral therapy for the acute exacerbation of COPD were 80% (n = 10) and 93.8% (n = 16) respectively. No patients died. As for the adverse events in the treatment with oral ZSR, grade 1 of diarrhea and liver dysfunction were seen in 10% and 10% respectively. There were no signicant differences in clinical cure rates between ZSR and parenteral therapy (p = 0.539). As for clinical success cases, patients who received ZSR stayed much shorter than patients who received parenteral therapy (7 vs 15 days, p = 0.135). In addition, the medical cost in the group of ZSR alone was less expensive than that of parenteral therapy for acute exacerbation of COPD. Conclusion ZSR is effective and safe for the treatment of acute exacerbation of COPD with acceptable tolerability. Besides, treatment with ZSR shorten the term of admission and save medical cost, compared to the patients who received parenteral therapy.

ELEVATED PLGF PREDICTING PNEUMONIA IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE USING INHALED CORTICOSTEROIDS THERAPY SHIH-LUNG CHENG, HAO-CHIEN WANG, SOW-HSONG KUO Chest Medicine, Far Eastern Memorial Hospital, Taiwan Introduction The increased incidence of pneumonia in patients with chronic obstructive pulmonary disease (COPD) using inhaled corticosteroid (ICS) therapy was noticed in previous several studies. We performed a retrospective study to elucidate the risk factors for pneumonia development. Besides, placenta growth factor (PlGF) biomarker would be evaluated to predict the pneumonia occurrence. Methods Patients diagnosed as having COPD from 2007 to 2008 were identied in the Far Eastern Memorial Hospital database. Every acute exacerbation was also recorded especial pneumonia event, which was conrmed by chest radiography. Serum levels of PlGF were assessed by a standardized ELISA method. Multivariate analysis was performed for pneumonia risk factors. Results 274 patients were diagnosed as having COPD during the study period and 29 patients suffered from pneumonia. The incidence was 10.6%. The rate was signicantly higher in patients with ICS therapy (20/29, 68.9%) compared with those without ICS (9/29, 31.1%) (p = 0.01). We stratied ICS therapy into medium dose (500 g/day uticasone and 640 g/day or Budesonide, 71 patients) and high dose (1000 g/day uticasone, 54 patients) of ICS into two groups. There was no statistically difference in pneumonia incidence between these two group (medium dose: 13/71, 18.3% vs. high dose: 7/54, 12.9%, p = 0.47). Multivariate analysis revealed that independent risk factors for developing pneumonia included forced expiratory volume in one second (FEV1) less than 40% of predicted (odds ratio (OR) 2.2, 95% condence interval (CI): 1.16.8), elevated C-reactive protein (CRP) over 4 mg/L (odds ratio (OR) 2.4, 95% condence interval (CI): 1.38.7), the presence of diabetes mellitus (DM) (OR 4.3, 95% CI: 2.113.6) and elevated PlGF levels over 40 mg/dl (OR 4.7, 95% CI: 1.910.4). Conclusion ICS therapy in patients with COPD could increase the risk of pneumonia. However, there was no difference of pneumonia incidence using medium or high dose of ICS. Additionally, elevated PlGF levels, advanced lung function status, elevated CRP level and DM were independent risk factors for pneumonia development.

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EVALUATION OF THE EFFECTIVENESS A COPD NURSE CLINIC IN A HONG KONG REGIONAL HOSPITAL HENRY POON CHUNG LEUNG, YUET KWAI CHAN, VERONICA LEE CHAN, YUK YIN CHONG, KIT CHING TSE, SHU WAH NG Respiratory Ward United Christian Hospital, Kwun Tong, Kowloon, Hong Kong Introduction Severe Chronic Obstructive Pulmonary Disease (COPD) is characterized by frequent exacerbation and hospital admissions. This underpins the need for more effective prevention and management strategies. The Department of Medicine & Geriatrics pioneers a COPD nurse clinic for high risk COPD patients, to improve management, prevent complications, reduce re-admission and improve outcomes. It also serves as a great opportunity for leadership development and specialty nursing development. Methods Objectives: Evaluate effectiveness of a COPD nurse clinic in reducing utilization of in-patient services and enhancing symptoms control of COPD patients. The framework of the nurse clinic includes structure, process and outcomes. Structure: The nurse-led clinic is run by very experience and welleducated respiratory specialty nurses. The independent role of the nurse is sometimes diffused when the patients are seen in setting attached to the ward or with a multidisciplinary team. Process: The main functions of nurse clinic are symptom management and complication prevention. The primary activities conducted in the nurse clinic are assessment and evaluation, health counseling, treatment and procedures and case management. Hotline is provided to the patients for health counseling and early follow-up arrangement. The specialty nurse employs a holistic approach to care and relies less on medications. Outcomes: The most sensitive indicators of nurse clinic intervention are symptom control, complication prevention and client satisfaction. Also, it would be expected that health services utilization of these patients under care of nurse clinic would be reduced or more cost-effective. Results A signicant reduction in unplanned re-admission (p < 0.05), AED attendance (p < 0.05) and symptoms control (p < 0.05) among patients (N = 110) recruited in the COPD nurse Clinic at 9 months after the establishment of the COPD nurse clinic. Conclusion COPD Nurse Clinic is effective in caring patients with COPD, this supports the introduction of a Nurse-led care in reducing utilization of inpatient services and enhancing symptoms control of COPD patients. More services outcomes remain to be explored such as complication prevention and hospital length of stay.

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EVALUATION OF PREVENTION AND TREATMENT WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE FOR ONE YEAR IN COMMUNITY HEALTH SERVICES CENTERS FAN LI, CAI YINGYUN, XU XUN, ZHANG XUEMIN Songjiang Branch of Shanghai Municipal First Peoples Hospital Afliated to Shanghai Jiaotong University, 201600, China Introduction To evaluate the prevention and treatment of chronic obstructive pulmonary disease for one year in community health service centers. Methods Casecontrol study was used for patients with COPD who visited Xiaokunshan and Xinbang community health service centers in Songjiang district of Shanghai. Results Among 132 patients diagnosed as COPD according to their pulmonary function, 61 were from Xiaokunshan and another 71 were from Xinbang. In these patients 47 from Xiaokunshan and 55 from Xinbang had nished one-year follow up data. No statistics difference was found between the two groups in FEV1 and symptoms, but the two groups were different at the following factors. (1) quality of life: The quality of life sore of patients from Xiaokunshan was 46.96 at rst visit and dropped to 39.12 after one year, score difference was 7.83. The quality of life sore of patients from Xinbang was 56.55 at rst visit and rose to 62.11 after one year, score difference was 5.56 (p < 0.000). (2) 6 minutes walking length: The 6 minutes walking length of patients from Xiaokunshan reduced from 361.66 at rst visit to 354.26 after one year, meanwhile the walking length of patients from Xinbang reduced from 398.07 to 351.18 (p = 0.008). (3) functional dyspnea evaluation: The functional dyspnea evaluation ratio of patients from Xiaokunshan was 0.4 at rst visit and fell to 0.34 after one year, The ratio of patients from Xinbang was 0.95 at rst visit and went up to 1.0 after one year (p = 0.038). (4) emergency and hospitalization: During the past one year 13 from Xiaokunshan and 53 from Xinbang had emergency treatment, and 4 from Xiaokunshan and 5 from Xinbang were hospitalized. 4 from Xinbang had died because of acute exacerbation of COPD, but none patient from Xiaokunshan died. Conclusion To increase prevention and treatment level in community general practitioners and patients with COPD and their familiarity would improve quality of life, reduce need for emergency and hospitalization, alleviate dyspnea and delay the decline of 6 minutes walking length.

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PREVALENCE OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN KOREA: THE FOURTH KOREAN NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY, 2008 KWANGHA YOO, YEON-MOK OH, YOUNG SAM KIM, YONG IL HWANG, IN-WON PARK, SANG-DO LEE, SE KYU KIM, YOUN KYOON KIM, SUNG KOO HAN, YOUNG TAEK KIM Konkuk University Hospital, 4-12 Hwayang-dong, Gwangjin-gu, Seoul, Korea Introduction Since the mortality rate and social burden of chronic obstructive pulmonary disease (COPD) have increased, continuous surveys for detecting the prevalence of COPD enable us to determine risk factors, detect potential patients, and establish early diagnosis and management protocols. We report the prevalence of COPD in 2008 using spirometry according to the fourth Korean National Health and Nutrition Survey results. Methods This survey was conducted by a nationwide stratied random sampling based on the census of the Korean Statistical Ofce. For 6,840 subjects with age 19 years, spirometry was performed by four trained technicians in the year 2008. In addition, information of residence, education, income, and smoking status along with COPD survey questionnaire were obtained. Results Airow obstruction (FEV1/FVC < 0.7) was detected in 8.8% of the subjects 19 years of age (males, 11.6%; females, 5.9%) and COPD was detected in 13.4% of the subjects 40 years of age (males, 19.4%; females, 7.9%). Of the subjects 19 years of age, the prevalence of current and former smokers was 23.7%, 17.2%, respectively and the prevalence of COPD was higher in current and former smokers than in never smokers. Approximately 95% of these patients showed mild-to-moderate COPD without apparent symptoms; only 2.4% of COPD patients had received a physicians diagnosis and 2.1% of COPD patients had been treated. The independent risk factors for COPD were smoking, old age, and male gender. Conclusion In Korea, although the prevalence of COPD is high, most of the COPD patients are underdiagnosed and undertreated.

CLINICAL OUTCOMES OF COPD PATIENTS WHO UNDERWENT 4-WEEK PULMONARY REHABILITATION AT THE UNIVERSITY OF PERPETUAL HELP DALTA MEDICAL CENTER REACH PROGRAM ALFONSO B BARRIENTOS JR, IMELDA MANUEL, JOSE EDZEL TAMAYO, RICARDO SALONGA University of Perpetual Help DALTA Medical Center, Las Pias City, Philippines Introduction COPD ranks 3rd most common cause of death worldwide by 2030 according to the World Health Organization. Exercise intolerance resulting from dyspnea or fatigue is often the chief symptom reported by patients with COPD. The degree of exercise intolerance roughly parallels the severity of the disease, but it is also distinctly present in patients with only mild. Methods This is a descriptive, prospective study to evaluate the effectiveness of four-week pulmonary rehabilitation. Changes in weight, O2 saturation, Post-bronchodilator FEV1 and FVC were measured, exercise tolerance and functional capacity using the 6-minute walk test and quality of life score using the Guyatts CRDQ. Results A total of 44 COPD patients were initially assessed with 30 subjects subsequently evaluated. Measurement of O2 saturations showed no signicant changes immediately after the pulmonary rehabilitation, however, signicant weight gain were observed from the study group. The functional capacity showed signicant changes immediately after the rehabilitation. In the quality of life, only the dyspnea score has signicant changes before and immediately after the rehabilitation (p = 0.0339). There were no signicant changes in the different parameters of quality of life. Signicant changes on both FEV1 and FVC respectively before and after pulmonary rehabilitation. Conclusion The 4-week pulmonary rehabilitation REACH program in UPHDMC has shown benets in exercise, functional capacity, pulmonary function test, weight and dyspnea score. Oxygen saturation as well as mastery, emotional and fatigue dimensions of quality of life showed no improvement after a 4-week pulmonary rehabilitation.

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PLASMA ADIPONECTIN, LEPTIN AND RESISTIN IN COPD AND ASSOCIATIONS WITH INFLAMMATORY BIOMARKERS SEVILAY BIRER, GONENC ORTAKOYLU, AYSE BAHADIR, FIGEN ALKAN, EMEL CAGLAR Yedikule Chest Hospital-Istanbul, Turkey Introduction Adiponectin is an adipose tissue-derived specic protein that has a role in energy homoestasis, that has a protective role against the development of insulin resistance and atherosclerosis and that exhibits anti-inammatory properties. We investigated serum adiponectin as a biomarker of systemic inammatory response and its relation with leptin, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and nitric oxide (NO) in chronic obstructive pulmonary disease (COPD) patients. Methods We studied 30 patients with stable COPD and 30 exacerbated and 20 healthy subjects. COPD patients were classied according to GOLD criteria. The adiponectin, leptin, resistin, ESR and CRP levels were measured in stable and exacerbated with COPD patients and control groups. In each group results are compared. The relationship between BMI (and), BODE index and adipokinin and COPD stage were studied. Results NO and adiponectin level in both groups of COPD patients were signicantly higher than the control group (p: 0.45 and p: 0.002). The difference between leptin and resistin levels was not signicant. Resistin levels were signicantly higher in exacerbated groups than stable COPD patients (p: 0.019). There was positive correlation between adiponectin and BODE index in stable patients. There was no signicant difference between COPD stage and adiponectin, leptin and resistin levels in COPD groups (stable and exacerbated). As the stage of COPD progressed the BMI decreased but the difference was not signicant. Conclusion In our study, since adiponectin and NO levels were signicantly higher in both exacerbated and stable COPD groups than control, it was considered these parameters would be a marker of inammatory response. As resistin levels were signicantly higher in exacerbated groups than stable COPD patients we thought it would be an inammatory marker that shows COPD exacerbation.

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DETERMINATION OF TIME-DELAY OF ENDOTRACHEAL AND TRACHEAL TUBE CUFF LOLITA BRIGIDA MICU, CELESTE MAE CAMPOMANES, JOANNE COSARE, MA JANETH SAMSON Institute of Pulmonary Medicine, St. Lukes Medical Center, Quezon City, Philippines Introduction Maintaining adequate ination pressure of the endotracheal tube and tracheal tube cuff is a key factor in preventing aspiration and ensuring no leaks during invasive mechanical ventilation. However, there are currently no guidelines regarding the frequency of cuff pressure monitoring. The objective of this study is to determine the rate of deation (time-decay) of the endotracheal tube and tracheostomy tube cuff in ventilated critical care patients. It is also our aim to determine the ideal frequency of monitoring for cuff pressures. Methods This is a cross-sectional study of all adult intubated or tracheostomized ventilated patients admitted in 3 critical units in a tertiary hospital. A single observer performed the cuff pressure determination using a handheld manometer. Baseline cuff pressure was noted. The cuff was reinated to the ideal median cuff pressure of 26 cm H2O. Cuff pressure was measured every hour until it decreased to below 20 cm H2O. Results A total of seventy patients were included in the study. The over-all cuff time-decay rate was determined to be at 5 cm H2O per hour. There was no statistically signicant difference (p = 0.73) between the cuff time-decay rate of the endotracheal and tracheostomy tube groups. The time for cuff pressure to decline to below minimum adequate pressure was determined to be at 2 hours.
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THE EFFECT OF PEAK AIRWAY PRESSURE ON THE RESPIRATORY COMPLICATION IN PATIENTS UNDERGOING LAPAROSCOPIC COLECTOMY KYUN KANG, JOON HWA HONG, CHONG HWA BAEK, YOUNG CHEOL WOO, JIN YUN KIM, SUN GYOO PARK Department of Anaesthesiology and Pain Medicine, Chung-Ang University College of Medicine, 224-1 Heukseok-dong, Dongjak-gu, Seoul, South Korea Introduction The purpose of this study is to evaluate the impact of high peak airway pressure on short-term postoperative outcome in the patients receiving laparoscopic colectomy. Methods A total 115 of consecutive laparoscopic colorectal procedures between April 2006 and December 2008 was used to evaluate the impact of high airway pressure on short-term postoperative outcome. These patients were divided into respiratory overloading group (Group O) or control group (Group C) according to the peak airway pressure. Patients in Group O were whose peak inspiratory pressure in spirometry were greater than 30 cmH2O at least once, and patients in Group C were whose peak airway pressure less than 30 cmH2O for the operation. For each patients, parameters relative to patient demographics, preoperative diagnosis, intraoperative events, postoperative course, and follow-up assessment were documented. Results There were no signicant differences between the groups with respect to preoperative parameters except age, ASA scores, BMI, A-aDO2 and PaO2. Intraoperatively, Group O had lower PaO2, and higher A-aDO2, VD/VT compared with group C. Group O had longer duration of operation and time at PACU. Postoperatively, group C has lower incidence of new cough and sputum production, abnormal breath sounds, fever, chest radiograph documentation of atelectasis or new inltrate, and physician documentation of atelectasis or pneumonia, consequently, lesser respiratory complication rate and O2 at discharge. Conclusion We cannot conclude whether elevated airway pressure caused respiratory complications or the patients with potential lung problem had elevated airway pressure during the surgery. However, we can conclude that the patient group with elevated peak airway pressure needs close observation and aggressive preventive measures for pulmonary complications.

Cuff Time-Decay Rate 60

50

40 Cuff Pressure

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OUTCOME OF PULMONARY REHABILITATION AMONG DIFFICULT TO WEAN PATIENTS ADMITTED AT THE PHILIPPINE HEART CENTER A RANDOMIZED CONTROLLED STUDY MARIE GRACE MALICDEM, BERNICE ONG-DELA CRUZ, PERCIVAL PUNZAL, TERESITA DE GUIA Division of Pulmonary and Critical Care Medicine, Philippine Heart Center, Quezon City, Philippines Introduction Pulmonary rehabilitation has shown its benet among patients with chronic obstructive pulmonary diseases even those with non-lung diseases. The idea that alternate care settings can provide alternatives among patients in the intensive care unit (ICU) especially on patients on long term ventilation has led to the proposal that patients can undergo rehabilitation and see its immediate and long term benets. Methods Patients at the ICU who were termed difcult to wean were enrolled in the study. They were randomized using computer generated number into those who would undergo pulmonary rehabilitation and to those who would not. An exercise protocol including breathing exercises, cycle ergometry and upper body exercises was provided to the patient who will undergo pulmonary rehabilitation. Independent T-test and MannWhitney U test were applied to continuous variables and chi-square test for nominal variables, respectively. Results A total of 24 subjects were enrolled in the study, equally divided into control and study groups. Results showed that patients who received pulmonary rehabilitation had longer time off the ventilator, had shorter days hooked to mechanical ventilator and had shorter hospital stay. They were also able to develop more capability to do activities of daily living such as sitting up on bed, eating and combing hair. Results however showed no statistically signicant difference. Seven out of 12 patients in the control group developed ventilator dependence compared to that of the study group which was only 3 out of 12, though not statistically signicant. Conclusion Although, there were a limited number of subjects, mechanically ventilated patients who underwent pulmonary rehabilitation showed a trend for them having a longer time off the ventilator, shorter days hooked to mechanical ventilator and shorter hospital stay.

20

10

1st hour 2nd hour 3rd hour Baseline Cuff Pressure Pressure Pressure Pressure (cm H2O) (cm H2O) (cm H2O) (cm H2O)

4th hour Pressure (cm H2O)

Conclusion Based on our results, cuff pressure measurement every 2 hours may be recommended in order to maintain cuff pressures within acceptable range since cuff time-decay rate is 5 cm H2O per hour. Maintaining cuff pressures within acceptable range may translate to decline in endotracheal stenosis and ventilator-associated pneumonia.

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INCIDENCE, CLINICAL PROFILE AND OUTCOMES OF VENTILATOR-ASSOCIATED PNEUMONIA IN A TERTIARY HOSPITAL RONALD PANALIGAN, JUDE GUIANG USTH Department of Medicine, Espana Manila, Philippines Introduction Pneumonia is still the most important nosocomial infection among critically ill patients receiving mechanical ventilation despite advancement in the diagnostic technology available, introduction of new antimicrobials and employment of preventive strategies. Our aim was to prospectively identify the occurrence of ventilator-associated pneumonia in a tertiary hospital as well as to determine its clinical prole and outcomes. Methods A prospective, observational study was performed including 52 patients with VAP in a tertiary hospital. All adult patients admitted who required mechanical ventilation regardless of site of care was included and followed up until successful weaning, discharge or death. Results During the twelve-month study period (May 1, 2009April 30, 2010), a total of 52 patients (7.6%) developed VAP among the six hundred and eighty six patients who received mechanical ventilation. Most common co-morbid conditions documented were diabetes mellitus and hypertension. Higher APACHE II scores (p =< 0.001), inappropriate antimicrobial use (p = 0.027) and presence of underlying malignancy (p = 0.03) are correlated with mortality. The most common pathogen isolated was Pseudomonas aeruginosa (23%) and carbapenems as the most commonly used antimicrobial. Mortality rate was 38.5%. Non-survivors had numerically longer ICU stay and length of mechanical ventilation.

RISK FACTORS ASSOCIATED WITH MULTI-DRUG RESISTANT PATHOGENS AMONG PATIENTS WITH HOSPITAL ACQUIRED PNEUMONIA ADMITTED AT PHILIPPINE GENERAL HOSPITAL (PGH) RUBY NOLIDO, LENORA FERNANDEZ Section of Pulmonary Medicine, UP Philippine General Hospital, Manila, Philippines Introduction Hospital-acquired pneumonia (HAP) is the most frequent and the most severe nosocomial infection encountered in the ICU, and hospital wards. The high-in hospital mortality rates for patients with HAP is correlated with inadequacy of initial empiric antibiotic treatment secondary to resistance of causative bacteria. Methods This is a prospective, observational cohort study on all adult patients admitted either in the ICU, Pay and Charity Wards of the PGH with a diagnosis of HAP or exhibit HAP during the hospital stay; and clinical diagnosis of HAP. Univariate analysis and logistic regression were used. Results 137 cases of nosocomial pneumonia were included, 95 (69%) developed HAP with multi-drug resistant organisms. 2 or more causative organisms were isolated in 59 of these cases. The mean age was 56 years old; 57 (42%) males, 80 (58%) females. Nosocomial pneumonia is highest in the ICU (103, 75%). 153 organisms were isolated from respiratory specimen and 2 from blood cultures. 115 pathogens were multi-drug resistant organisms. The 3 most common multi-drug resistant pathogens isolated were A. baumanii (n = 50), P. aeruginosa (n = 16) and K. pneumonia ESBL (n = 16). A. baumanii has the highest susceptibility rate (45%) for ampicillin-sulbactam and highest resistance rate to ciprooxacin. P. aeruginosa has the highest susceptibility rate to amikacin (64%) and highest resistance rate to ceftriaxone (90%). K. pneumonia-ESBL isolates has the highest susceptibility rate to meropenem and imipenem (100%) and highest resistance rate to ceftriaxone and ampicillin-subactam (100%). The signicant risk factors identied were: (1) 5 days or more hospital admission prior to HAP, p-value = 0.03; (2) length of intubation or mechanical ventilation of 5 or more prior to HAP, p-value = 0.006; (3) antibiotic use within 3 months prior to the onset of HAP, p-value = 0.032 (BLIC, p-value = 0.015) and (4) involvement of >1 lobe based on chest radiograph, p-value of 0.04. Conclusion This study reveals that the length of hospital stay, duration of mechanical ventilation and recent antibiotic use prior to the onset of HAP, and involvement of >1 lobe based on chest radiograph have greater risk of developing HAP with multi-drug resistant organisms. Early recognition of these risk factors and prevention intervention may help decrease morbidity and length of hospital stay.

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PERIOPERATIVE VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION FOR CRITICAL AIRWAY STENOSIS SEONGJOO PARK, JIN YOUNG HWANG, JIN HEE KIM, SUNG HEE HAN Department of Anesthesiology & Pain Medicine, Seoul National University Bundang Hospital, Seoul, South Korea Introduction Conventional ventilation techniques have been used successfully for critical airway stenosis. These include beroptic bronchoscope-guided intubation, supraglottic airway, endotracheal or endobronchial intubation at operative eld, high frequency jet ventilation, etc. However, in patients with fatal airway obstruction or severely depressed pulmonary function, cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO) can be used although these situations are uncommon indications for ECMO. Especially, venovenous (VV) ECMO can be used for pure pulmonary support. We describe three cases of airway surgery using VV ECMO. Methods Case 1) A 94-year-old female was diagnosed as supraglottic mass, displaced epiglottis and extended to vocal cord. We expected difcult intubation. However, she refused surgical airway. So we performed biopsy with VV ECMO under general anesthesia. Case 2) An 87-year-old female was diagnosed as upper esophageal cancer surrounding right carotid artery and invading to trachea and thyroid gland. She suffered with progressive resting dyspnea after radiotherapy and needed tracheostomy. We used VV ECMO because of high risk of bleeding, adhesion after radiotherapy and tracheal stenosis. Case 3) 63-year-old male had tracheoesophageal stula 1 cm in diameter accompanied with esophageal cancer, which opened to left side of carina. And chest CT shows aspiration pneumonia and radiation pneumonitis. We underwent stula repair via conventional one lung ventilation with 35 Fr. Left-sided double lumen tube. But after right bronchial incision, ventilation was impossible. So we decided to convert to VV ECMO, and then performed bronchial exploration. Conclusion VV ECMO can be used in case of near-fatal airway obstruction and has some advantages compared with VA ECMO.

Table 1.

Univariate analysis for mortality in 52 VAP patients

Conclusion In our setting, current VAP incidence rate is 7.6% with mortality of 38.5%. This highlights the current magnitude of VAP which should prompt hospital administrators and health care workers to complement rational antibiotic use with non-pharmacologic strategies to at least decrease VAP incidence and alleviate its burden especially in a developing country.

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THERAPEUTIC EFFECT OF ERYTHROPOIETIN IN RAT MODEL OF SPINAL CORD ISCHEMIA/REPERFUSION INJURY SEONGJOO PARK, SUNG HEE HAN, JIN YOUNG HWANG, JIN HEE KIM Department of Anesthesiology & Pain Medicine, Seoul National University Bundang Hospital, Seoul, South Korea Introduction Recombinant human erythropoietin (EPO) has been reported to attenuate ischemia/reperfusion (I/R) injury of spinal cord when it is administered at the time of insult. However, the therapeutic effect of EPO in a spinal cord I/R injury has not been investigated yet. Therefore, we evaluated the therapeutic effect of EPO in spinal cord I/R model in rats. Methods Spinal cord I/R injury was induced with a balloon catheter placed in descending thoracic aorta. Twenty four hours after the I/R injury, rats were treated with recombinant human erythropoietin (1000 IU/kg) (group EPO) or the same volume of saline (group S). Neurologic function was assessed with motor decit score (0 = normal, 4 = no movement) for 3 days. The score 3 was considered as paraplegia. For histopathologic examination, the transverse section of lumbar spinal cord was stained with hematoxylin and eosin. The degree of inammation (0 = none, 3 = severe) was scored by a blind investigator. The number of paraplegic rat and degree of inammation was compared (Fishers Exact test or MannWhitney U test) between the groups. Results The number of paraplegic rats were not different between the group at 72 hours after the surgery (6/7 vs. 6/7, group S vs. group EPO, respectively). The degree of inammation was not different neither (2.71 0.75 vs. 2.57 0.78, group S vs. group EPO, respectively). Conclusion Therapeutic administration of EPO, 1000 U/kg given 24 hours after repefusion, did not offer any protective effect against I/R injury in rat model of spinal cord I/R injury.

PCI TECHNIQUES WITH BALLOON INFLATION IN A DIFFICULT CASE WITH HEMOPTYSIS UNABLE TO CANNULATE BRONCHIAL ARTERY A CASE PRESENTATION SEZAKI KAZUNORI, NAKAGAWA TAKASHI, NAKAMURA KENTARO, KASAOKA YUJI, INOUE YUZURU, TANIGUCHI YUKIKO, UOTANI CHIZUE, SUZUKI FUMIO, MURAKAWA YUJI The Cardiovascular Medical and Surgical Center, Shin-Yamanote Hospital, Japan Anti-Tuberculosis Association, 3-6-1 Suwacho, Higashimurayama, Tokyo, Japan Introduction Massive abrupt hemoptysis often requires emergent treatment to avoid asphyxiation. Although arteriographic embolization is an effective tool for this aim, 5 to 10 percent of the patients have unsuccessful angiographic control of bleeding. Inability to cannulate the bronchial artery (BA) is one of the biggest problems to contribute to the outcome. Methods We encountered a patient of massive bronchostaxis with a severe stenosis in the culprit BA. Results Case Presentation: A 69-year-old male entered our hospital because of recurrent hemoptysis. For over past 4 years, he repeated occasional bronchostaxis due to secondary fungal infections to inactive tuberculosis in the upper lobes. The chest CT demonstrated fungal ball and the aspergillus antigen was positive. He declined bronchoscopy and received conservative therapy with styptics and itraconazole. Two weeks after the admission, he developed massive abrupt hemoptysis followed to asphyxiation and cardiopulmonary arrest. We identied two individual right bronchial arteries (BAs) and an additional artery to the right upper lobe, and a left bronchial artery to the left upper lobe with the culprit vessels by the selective bronchial arteriography, performed after successful CPR. Two right-sided BAs and one left-sided BA were easily embolized by hematostatic coils. The additional artery to the upper lobe arouse just below the aortic arch. Its branching portion had a severe narrow stenosis that made difcult to cannulate stably to the orice nor the delivery of hemostatic coils. Thus, we initially advanced a PCI (percutaneous coronary intervention) guide-wire to the vessel and inated a 1.5 mm PCI balloon at the 99% stenotic site of the vessel, and then successfully deliver hematostatic coils. After the procedures, the bronchostaxis subsided completely. Conclusions In patients with hemoptysis unable to cannulate narrow BA, PCI techniques with balloon ination are feasible to support angiographic embolization.

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AEROSOLIZED BOVINE LACTOFERRIN PROTECTS AGAINST HYPEROXIC LUNG INJURY CHIH-CHING YEN, CHUAN-MU CHEN Department of Internal Medicine, China Medical University Hospital, Taiwan Introduction Long-term exposure to high levels of oxygen, usually required for ventilatory support for acute respiratory distress syndrome (ARDS), results in further lung injury. How to protect lung from oxygen toxicity is an important issue in the treatment of ARDS. Lactoferrin (LF) is an iron-binding glycoprotein found in milk and various external secretions such as saliva, tears, airway secretion, and granules of neutrophils. This protein has a number of biological functions, including antimicrobial, anticancer, antioxidant, and immunomodulatory effects. It is considered to be an important component of the host defense in airway. The present study investigates the hypothesis that LF had immunomodulatory and antioxidant effects, and could protect the lungs against hyperoxic injury. Methods An aerosol delivery system in the hyperoxic (FiO2 80%) injury model was developed to test the effects of aerosolized bovine LF (bLF) on mice. Results We have found that aerosolized bovine LF attenuates the severity of inammation and apoptosis in lungs, reduces proinammatory cytokines (IL-1, IL-6) production, and increases survival after 6 days in hyperoxia (LF treatment group: 66% vs. 33% in control group). Conclusion Our results suggest that LF in airway protects animals against hyperoxic lung injury.

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QUALITY OF CARE FOR PATIENTS ON NON-INVASIVE VENTILATION SHU WAH NG, YUEN YEE CHAN, KEI WAI YEUNG, KAM FAI WONG, CHUNG LEUNG POON, KIT CHING TSE, SIU KEUNG TANG, VERONICA LEE CHAN, CHUNG MING CHU United Christian Hospital, 130, Hip Wo Street, Kwun Tong, KLN, Hong Kong, China Introduction Non-Invasive Ventilation (NIV) is a supportive therapy used to maintain adequate oxygenation and ventilation in patients with respiratory failure. Certain randomized control trial and systematic review has shown that it can avoid complications of endotracheal intubation, maximize quality of life and prolong survival. NIV is also widely used in Hong Kongs hospitals. In line with corporate service plan, all NIV machine was modernized and unied in an acute district hospital. Also, a continuous quality improvement program has been implemented since 2007. The program aims to set up a mechanism to enhance safe and quality of care for patients on NIV in the hospital. Methods Our service and practice on care of patient on NIV was reviewed to identify areas for improvement, especially workow and care process. The guideline was revised and updated with reference to corporate Nursing Standard for Respiratory Care; No. 2 Care of Patient on Non-Invasive Positive Pressure Ventilation and best available evidence e.g. from BTS. Also, all patients on NIV were registered in a respiratory ward to facilitate communication and comprehensive management. Besides, there were seven lessons conducted since 2007 for 215 colleagues in a cluster. Re-demonstration or quiz was required for candidates to test their competence. Finally, all NIV machine were centralized in a respiratory ward for storage, maintenance, distribution, utility trend monitoring and terminal disinfection in order to maintain a safe and effective utilization. Quality was assured by practical guideline, phone and out-reach consultation, and video available in hospital webpage. Results A mechanism was established in place to ensure the safe and effective care for patients on NIV. A practical guideline with reference to cooperate guideline and best available evidence was established. Nearly all (98%) candidates were satised with the training programs. For the course in advanced level, colleagues knowledge was signicantly improved after the lesson (p-value < 0.001). Finally, workow and logistics of the NIV service was redesigned. Conclusion It is important to have a mechanism in place for quality assurance for caring patients on NIV. Staff competence on caring patients on NIV has been enhanced. More services outcomes remain to be explored such as compliance rate and hospital length of stay.

EPIDEMIOLOGY OF CANDIDA BLOODSTREAM INFECTION IN NAGASAKI MEDICAL CENTER, NAGASAKI, JAPAN KOICHI IZUMIKAWA, KATSUJI HIRANO, EISUKE SASKI, AKITOSHI KINOSHITA, YOSHIFUMI IMAMURA, TAIGA MIYAZAKI, MASAFUMI SEKI, HIROSHI KAKEYA, YOSHIHIRO YAMAMOTO, KATSUNORI YANAGIHARA, SHIGERU KOHNO Nagasaki University Graduate School of Biomedical Sciences, Department of Molecular Microbiology and Immunology, 1-7-1 Sakamoto, Nagasaki 8528501, Japan Introduction Candida bloodstream infection is one of most important infection due to its high mortality. The increase of non-albicans Candida spp. is a major concern since they are relatively resistant to azole antifungals. The newer antifungal drugs such as echinocandins, voriconazole, and liposomal amphotericin B have become available in last ve years in Japan and they may be contributing to improvement of outcome of Candida bloodstream infected patients. It is also important to understand the epidemiological character of Candida infection at local site, therefore we conducted the epidemiological study of recent Candida bloodstream infection including drug-susceptibility test at Nagasaki Medical Center with 643 beds located in Central Nagasaki, Japan. Methods We retrospectively searched Candida spp. isolated from blood culture between January, 2005 and December, 2009 in the database of Department of Laboratory Medicine, Nagasaki Medical Center. Blood culture samples were tested using the BacT/Alert system (bioMeriux). Candida spp. was identied by VITEK 2YST system (bioMeriux). Drug-susceptibility was assessed with ASTY (Antifungal Susceptibility Testing of Yeasts) kit (Kyokuto pharmaceutical industrial). Results A total of 43 Candida spp. (43 cases) was isolated from 2004 blood culture positive samples (2.2%). These isolates were C. albicans (20 isolates, 46.5%), 7 of C. parapsilosis (16.3%), 3 of C. tropicalis (7.0%), 5 of C. glabrata (11.6%), 2 of C. krusei (4.7%), 3 of C. famata (7.0%), 1 of C. guilliermondii (2.3%), 1 of C. magnoliae (2.3%), and 1 of Candida spp. (2.3%). There was no signicant increase of the annual frequency of Candida spp. between 2005 and 2009. The annual isolation rates of C. albicans in all Candida bloodstream infection were 20.0% (2005), 33.3% (2006), 66.7% (2007), 40.0% (2008) and 60.0% (2009). No signicant increase of non-albicans Candida spp. was recognized between 2005 and 2009. Overall 2, 2, 1 and 1 of all 23 non-albicans Candida spp. were resistant to amphotericin B, uconazole, itraconazole and voriconazole, respectively. No isolates were resistant to micafungin. Conclusion There was no remarkable increase of non-albicans Candida spp. isolation and no emergence of drug-resistant strains between 2005 and 2009 at Nagasaki Medical Center. Continuous surveillance of antifungal resistant Candida spp. is required for optimizing patient management.

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ADAPTIVE SUPPORT VENTILATION FOR FAST TRACHEAL EXTUBATION AFTER CARDIAC SURGERY POLLY DOMINGO, FERNANDO AYUYAO, AILEEN GUZMAN-BANZON, WILLIAM DEL POSO Division of Pulmonary and Critical Care Medicine, Philippine Heart Center, Quezon City, Philippines Introduction Rapid tracheal extubation is a major component of recovery post operatively thus many different strategies have been proposed to reduce the duration of mechanical ventilator after surgery, Adaptive support ventilation is a mode of ventilation is designed to accommodate both the passive and actively breathing patients. Due to its versatility, we therefore hypothesize that ASV could accelerate mechanical ventilator weaning after cardiac surgery. Methods Patients were allocated to two parallel Groups, one treated with an ASV-based protocol (group ASV), the other with a standard protocol of respiratory weaning T-piece (group control). Results There were no differences between groups in the duration of weaning, length of tracheal intubation, ICU and hospital stay. Moreover no patient from both arms of the study required reintubation. Conclusion In our study it showed that ASV was comparable to T-piece, since there was no signicant difference in the total duration of weaning, total length of intubation, as well as length of ICU and hospital admission between the modes of weaning.

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ACUTE RESPIRATORY DISTRESS SYNDROME SECONDARY TO PULMONARY LEUKOSTASIS TREATED SUCCESSFULLY WITH LEUKAPHERESIS AND HIGH DOSE HYDROXYUREA MARDIAH SUCI HARDIANTI1, IKA TRISNAWATI2, SUMARDI2, EKO BUDIONO2, KARTIKA WIDAYATI TAROENO-HARIADI1 1 Division of Hematology-Medical Oncology, and 2Division of Pulmonology, Department of Internal Medicine Faculty of Medicine Gadjah Mada University/DR. Sardjito Hospital, Yogyakarta, Indonesia Introduction Acute Respiratory Distress Syndrome (ARDS) is one of several causes of acute respiratory failure in patients with cancer.1 Such condition in leukemic patients can be a result of a severe pulmonary leukostasis involving perivascular tissue.2 A prompt and aggressive cytoreduction signicantly reduce mortality.3 A 64-year-old CML in blastic crisis patient presented to our hospital with 2 weeks of progressive dyspnea and weakness worsened in the last 3 days. She was rstly diagnosed for CML in chronic phase in September 2005 and has been stable for 5 years with Hydroxyurea 2 500 mg. She stopped her routine treatment since 7 months before developing current symptoms. She was conscious, heavily dyspneic and tachycardic. There were heavy crackles bilaterally on lung exam with no jugular venous distention. She had a massive hepatosplenomegaly and mild edema in her lower extremities. WBC count was 466,000/mm3 with 40% blasts, Hb of 6.2 g/dl and platelet count of 229.000/ mm3. Imaging studies showed bilateral diffuse inltrates and comet tails images in both lungs supporting a pulmonary edema.3 A urin culture showed an E. coli infection. Blood cultures showed no infection. Blood gas analysis showed an ARDS. Analysis of ne needle aspiration of the lung conrmed an inltration of myelocytes and myeloblasts. She was planned to have a mechanical ventilation support in ICU before then undone due to economical reasons. She underwent aggressive cytoreduction by a series of leukapheresis consisting of 7 cycles processing 1,680 cc of blood producing 302 cc of buffy coat, high dose Hydroxyurea 1 2,000 mg. She also received 3 bags of red cells following the leukapheresis, normal saline infusion 2,000 cc/day, Allopurinol 1 200 mg, Ceftriaxone 1 g/12 hours, Furosemide 20 mg/day and Pentoxylline 2 400 mg. Her clinical condition gradually improved and fully recovered on day-7. Chest x-ray evaluation showed an improvement of the diffuse bilateral inltrates, while laboratory examination revealed WBC count of 78,910/mm3 and Hb 10.2 g/dl. Conclusion Data from clinical, laboratory, imaging studies, and analysis from ne needle aspiration of lung tissue concluded a severe pulmonary leukostasis. The patient was successfully managed by leukapheresis and high dose Hydroxyurea. References 1. Azoulay E, Fleux F, Moureu D, et al. Acute monocytic leukemia presenting as acute respiratory failure. Am J Respir Crit Care Med 2003; 167: 132933. 2. Agricola E, Bove T, Oppizzi M, et al. Ultrasound comet-tail images: a marker of pulmonary edema. A comparative study with wedge pressure and extravascular lung water. Chest 2005; 127; 16901695. 3 Majhail NS., Lichtin AE. Acute leukemia with a very high leukocyte count: confronting a medical emergency. Clev Clin J Med 2004; 71: 63337.

THE EFFECT OF USING ENDOTRACHEAL TUBE WITH SUB-GLOTTIC SECRETION DRAINAGE VERSUS CONVENTIONAL ENDOTRACHEAL TUBE IN PREVENTING VENTILATOR-ASSOCIATED PNEUMONIA AT ST. LUKES MEDICAL CENTER A RANDOMIZED CLINICAL TRIAL ANNE ESTRELLA, CELESTE MAE CAMPOMANES, MYRNA BAARES Institute of Pulmonary Medicine, St. Lukes Medical Center, Quezon City, Philippines Introduction Mechanical ventilation (MV) is a fundamental feature of modern intensive care unit (ICU) care. Unfortunately, MV is associated with a considerable risk of ventilator-associated pneumonia (VAP). It is the most common nosocomial infection in the intensive care unit and is associated with major morbidity and attributable mortality. Endotracheal-tube biolm formation may play a causal role in sustaining tracheal colonization and also have an important role in late-onset VAP caused by resistant organisms. Aspiration of microbe-laden oropharyngeal, gastric, or tracheal secretions around the cuffed endotracheal tube into the normally sterile lower respiratory tract results in most cases of VAP. Development of fever, increased white blood cell count, and new or changing lung inltrate on chest x-ray are all signs of VAP. Methods General Objective: To compare the incidence of VAP using the with sub-glottic secretion drainage (ETT-SSD) versus the conventional endotracheal tube (C-ETT). Design: A randomized clinical trial. Patients: We studied 53 adults patients intubated in the Emergency Room in St. Lukes Medical Center using ETT-SSD versus the C-ETT with expected duration of MV >48 hours. Intervention: Patients were randomly assigned to receive either the ETT-SSD or the C-ETT. Outcome Measurements: To determine the incidence of VAP, total duration of MV, duration of MV prior to the onset of VAP, CCU length of stay, extubation, mortality rate and microbiology of VAP. Results A total of 34 patients (64.2%) developed VAP. Sixteen patients (61.5%) in the study group and 18 patients (66.7%) in the control group. No signicant differences were found in the VAP incidence (p = 0.779), total duration of MV, duration of MV prior to the onset of VAP, critical care unit (CCU) length of stay, extubation and CCUs mortality rate. All patients with a diagnosis of VAP were treated with antibiotic. Conclusion ETT-SSD did not reduce the incidence of VAP.

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ADVANCE DIRECTIVES AND WITHDRAWAL OF LIFE SUPPORT IN TERMINALLY ILL PATIENTS: A DISCUSSION WITH PULMONOLOGISTS ISSER SUGAY, MA ABIGAIL RIVERA, CHRISTINE AGATHA UNTALAN, PATRICK GERARD MORAL Center for Respiratory Medicine, University of Santo Tomas Hospital, Manila, Philippines Introduction Disclosing a terminal diagnosis in patients is not always easy and comfortable. While the patient has the right to information, sometimes the clinicians are asked by the relatives no to disclose the diagnosis to the patient. Moreover, there is always a need to explain to the patient possible life support measures that are extraordinary such as intubation or the need for an invasive procedure. The purpose of this survey was to determine the opinions of the pulmonologists in such situations. Methods A symposium regarding end of life care for practicing physicians (mostly pulmonary specialists) was held last March 2008. Keypads were distributed to the attendees at the start of the conference. Several case vignettes were presented and questions regarding discussion of disclosure of diagnosis, advanced directives, and withdrawal of life support were posted. The respondent were given time (30 seconds) to choose from ve alternatives. The results and percentages were shown after each question. Results As practicing pulmonologists, majority (46.7%) are uneasy in disclosing terminal illness to their patients, and when asked by the relatives not to disclose the diagnosis to the patient, most clinicians (55.6%) would try to convince their relatives to disclose the information. However a small percentage (5.6%) will withhold the diagnosis to the patient. When asked regarding about a patient with malignant terminal illness, majority (42.1%) are still uneasy with withdrawal of life support. In cases of iatrogenic complications in the management of a terminally ill patient, majority (41.2%) would admit to the family as soon as the error is discovered, while a minority (11.8%) would withhold the information if there is no adverse effect on the patient. In cases when the relatives decided on terminal weaning, the most common method being used is T-piece weaning without medications given (50%). When asked should extubate the patient, majority (43.8%) answered the main attending physician. When given a case of a patient with an ominous outcome and eventually expired, majority (57.1%) still thinks that it is ethical to charge a professional fee. Conclusion In our setting, pulmonologists are uneasy in disclosing a terminal illness their patients as well as in withdrawing life support. A small number would withhold the diagnosis from a patient when asked by the relatives. T-piece weaning is the most common method used by the pulmonologists in terminal weaning. Charging a professional fee for cases of poor prognosis is ethically acceptable.

BENEFITS OF RESPIRATORY HOME-VISITATION PROGRAM FOR DOMICILIARY INVASIVE MECHANICAL VENTILATION HENRY POON CHUNG LEUNG, YUEN YEE CHAN, CHUNG MING CHU, SHU WAH NG, KIT CHING TSE Respiratory Ward 6A, Block S, 130 Hip Wo Street, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong Introduction Throughout the world, domiciliary invasive mechanical ventilation (IMV) is increasingly employed to treat patients suffering chronic respiratory failure, diseases that have been treated by IMV include restrictive thoracic diseases (RTD), neuromuscular disorders, chronic obstructive pulmonary disease (COPD) and varies other causes of nocturnal hypoventilation syndrome. In order to providing specialized medical and nursing care such as changing tracheostomy tube and ventilatory care to the IMV patients in the community, a Respiratory Home-Visitation Program has been implemented since year 2009. Methods Objectives: To examine outcome measures of a Respiratory Home-Visitation Program that provided services to domiciliary invasive mechanical ventilation (IMV). The Home-Visitation Program aims to assess, plan, implement and evaluate the care provided to the domiciliary IMV patients in the community. A team involved doctor and respiratory specialized nurses will conduct home visit to patient with domiciliary IMV monthly. During home visit, home environment for any obstacles to care or to emergency evacuation, care plans and hospital discharge orders will be reviewed. Skills on tracheostomy and ventilatory care demonstrated by the caregivers will be reassessed and the ventilator settings and its alarms will be checked. Results Patients and the caregivers were satised with the home-visit service they receive, the caregivers generally agreed that the service can minimize the transportation of the ventilator-dependent individuals from the community to the hospital for medical and nursing follow-up and changing tracheostomy tube or PEG tube, thus reducing the risk of hospital acquired pneumonia (HAP) and utilization of the in-patient services. Conclusion Domiciliary invasive mechanical ventilation (IMV) allows the ventilator-dependent patients to have the opportunity to live at home with their families and receive care. The Respiratory Home-Visitation Program serves a way to provide specialized respiratory care to them in the community and enhance the network between hospital and community especially for these vulnerable individuals. Safety and quality are inherent in the use of assisted ventilation equipments and improve the quality of life of the patients and his family in a secure environment.

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RESULT OF PERCUTANEOUS LUNG NEEDLE BIOPSY UNDER CT-GUIDANCE EISUKE MATSUDA, KAZUNORI OKABE, HIROMASA YAMAMOTO, SEIKI KOBAYASHI, HIROYUKI TAO, KAZURO SUGI Chest Surgery, Ymaguchi-Ube Medical Center, Ube City, Yamaguchi, Japan Introduction Percutaneous lung needle biopsy under CT-guidance is useful method to diagnose lung nodule. But there are some reports of complications including air embolization and dissemination of cancer cells. Purpose of this study is to evaluate the efcacy and the risk of complications in patients who underwent percutaneous lung needle biopsy under CT-guidance. Methods From April 2006 to March 2008, seventy-two patients with lung nodule underwent percutaneous lung needle biopsy under CT-guidance in our hospital. These seventy-two cases were investigated about pathological diagnosis and complications. Results We obtained pathological diagnosis in 60 cases, fty-six of them were malignancy, two were aspergillosis, remainder two were mycobacterial infection. Twelve cases could not be diagnosed. We obtained the results of percutaneous lung needle biopsy under CT-guidance that Sensitivity, Specicity and Accuracy were 86.2%, 57.1% and 83.3% respectively. Accuracy of the lesion more than 2 cm was 92.5%, and 57.8% in 2 cm or less. Pneumothorax and pulmonary hemorrhage occurred in 11 cases (15.2%) and 21 cases (29.1%) respectively. Air embolization and dissemination of cancer cell did not occurred in our experience. Nodule size of cases with complications was smaller than that of cases without complications signicantly. Distance from pleura to nodule was longer in cases with complications than cases without complications signicantly. Conclusion In our experience, pneumothorax and pulmonary hemorrhage occurred frequently, but severe complications including air embolization and dissemination of cancer cell did not occurred. Pneumothorax and pulmonary hemorrhage occurred in small and deep lesions more frequently. Percutaneous lung needle biopsy under CT-guidance was useful to diagnose the lesion more than 2 cm. We should investigate other means including partial resection for the lesions 2 cm or less.

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LUNG RADIOLOGY OF ATELECTASIS SECONDARY TO MUCOID SECRETION MIMICKING LUNG MALIGNITY: A CASE REPORT KUTHAN KAVAKLI, DENIZ DOGAN, TASCI CANTURK, METIN OZKAN, HASAN CAYLAK, ONUR GENC Gulhane Military Medical Academy (GMMA), Ankara, Turkey Introduction Retained secretions and atelectasis are the common problems of patients of Intensive Care Unit and Thoracic Surgery. The diagnosis is not challenging when the patient is a critically ill or subjected to an operation. However it is a very hard clinical condition when the patient is out of hospital. Results A 58-year old male patient admitted to our clinic with dyspnea and back pain. The chest X-ray revealed nearly total left lung atelectasis and left mediastinal shift. The thorax CT ndings were including volume loss of left hemithorax, atelectasic of the left lung and pleural effusion which was leading to perform bronchoscopy. The prediagnosis of patient was lung cancer manifesting with endobronchial lesion. When we performed bronchoscopy, there was no endobronchial lesion but existing extensive mucoid secretion coming from left main bronchus was aspirated. Post-bronchoscopy chest X-ray revealed nearly full expanded lung. Conclusion We reported a case who had atelectasis secondary to mucoid secretion due to loss of cough reex related with severe back pain mimicking primary lung malignity.

LONG-TERM RESULTS OF INTERVENTIONAL BRONCHOSCOPY IN THE MANAGEMENT OF POST-OPERATIVE TRACHEOBRONCHIAL STENOSIS BYEONG-HO JEONG, KYEONGMAN JEON, SANG-WON UM, WON-JUNG KOH, GEE YOUNG SUH, MAN PYO CHUNG, O JUNG KWON, HOJOONG KIM Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul, South Korea Introduction The role of bronchoscopic management in post-operative tracheobronchial stenosis is not well dened. To investigate the role of bronchoscopic intervention in the management of post-operative tracheobronchial stenosis, the current retrospective study was conducted at a tertiary referral hospital. Methods A retrospective review was conducted of 31 patients underwent 106 bronchoscopic interventions (including ballooning, bougienation, neodymium-yttrium aluminium garnet laser resection, and/or stent insertion) between January 2000 and July 2010, and were followed for a median of 34 months. Results Silicone stents were required in 20 out of 31 (65%) patients to maintain airway patency. Bronchoscopic intervention provided immediate symptomatic relief in 97% of the patients. After airway stabilisation, stents were removed successfully in 7 out of 20 (35%) patients at a median of 7 months post-insertion. Three patients out of 31 (10%) failed to do successful intervention, and they couldnt undergo surgical correction because of their poor condition. Of 106 bronchoscopic interventions, acute complications included: pain (n = 14); fever (n = 7); dyspnea (n = 5); asthma attack (n = 1); atrial brillation (n = 1); and pneumomediastinum (n = 1) without mortality. Stent-related late complications, such as restenosis (45%), granulation formation (34%), stent migration (32%), mucostasis (31%), and malasia after removal of stent (16%), were controllable during a median follow-up of 34 months. Conclusion In conclusion, bronchoscopic intervention could be a useful and safe method for treating post-operative tracheobronchial stenosis.

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RISK OF CARDIOVASCULAR COMPLICATIONS AFTER BRONCHOSCOPIC PROCEDURES YONGSEON CHO, MINSOO HAN, DONG-JIB NA Respiratory Medicine, Eulji Medical School, South Korea Introduction Bronchoscopic procedure is an essential tool to diagnose the respiratory disease. There are few reports about cardiovascular complications related bronchoscopy. To evaluate the risk of cardiac complications after bronchoscopy, we collected data between May 1, 2009 to November 30, 2009 Methods Forty-two beroptic bronchoscopies (FBS), including 22 explorative bronchoscopies (EB) (52.38%), 14 bronchial biopsies (BB) (33.33%), 6 broncho-alveolar lavages (BAL) (14.28%). All cases were carried out using a exible bronchoscope. Results The total number of complications recorded was 5 (11.9% of the cases examined), including 2 chest pain (4.76%) after procedure, 3 (7.14%) hypoxemia during the endoscopic procedures and 7 fever (16.6%) in the twelve hours following FBS. There were no elevations of cardiac enzymes. No elevations of ST segment in ECG were recorded. 2 (4.76%) cases of atrial brillations were recorded in the one hour following FBS. All complications were recovered without serious events or intensive care units management. Conclusion This study shows that exible bronchoscopy is a relative safe method with low incidence of cardiovascular complications. Experienced operators of the medical and nursing team seem to play a important role in reducing complications and careful examinations and history takings before bronchoscopy are essential to reduce the cardiovascular events.

ENDOBRONCHIAL ACTINOMYCOSIS CAUSED BY ASPIRATION A SQUIDS JAW PLATE WHICH IS A KIND OF SNACK IN JAPAN MATSUNUMA RYO, OHKUNI YOSHIHORO, KOMATSU AKINA, NAKASHIMA KEI, ANDO KATSUTOSHI, ASAI NOBUHIRO, HASEGAWA KEIKO, MISAWA MASAHUMI, KANEKO NORIHIRO Respiratory Medicine, Kameda Medical Center, Kamogawa City, Chiba, Japan Introduction Endobronchial actinomycosis is rare. And the association of endobronchial actinomycosis with the presence of a squid jaw plate has not previously been reported. Methods A 63-year-old man presented with a tumorous shadow in his right lower lung eld in his chest x-ray, was admitted to our hospital to determine if it reected it was carcinoma. Computed tomography revealed solitary lesion (15 16 mm in size) in the right lower lobe. Fiberoptic bronchoscopy was performed. It demonstrated vegetations and some blistered material in the right lower lobe bronchus. Results Microscopic examination of the biopsy specimen demonstrated Actinomyces colony, which grew in the material of squid jaw plate. The patient had eaten a squid jaw plate which was a kind of nibbles in Japan. The patient responded well to penicillin therapy and chest x-ray and CT scan ndings completely cleared in six months. Conclusion To our knowledge, the association of endobronchial actinomycosis with the presence of a squid jaw plate has not previously been reported, thus should be included in the differential diagnosis of endobronchial tuberculosis or cancer presenting as endobronchial vegetations.

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USE OF AUTOLOGOUS BLOOD IN MANAGEMENT OF PERSISTENT AIRLEAK DUE TO BRONCHOPLEURAL FISTULA YASHU CHANG, ANDREW VEALE Department of Medicine, North Shore Hospital, Auckland, New Zealand Introduction Bronchopleural stula is associated with high mortality and morbidity. Management is particularly challenging in patients with signicant comorbidities who are unlikely to tolerate surgical procedures. We report a case of signicant airleak due to iatrogenic bronchopleural stula which was successfully treated by combination of endobronchial blood clot and blood pleurodesis. Methods An eighty-six year old ex-smoker with known emphysema, previous right pneumonectomy for lung cancer, and pulmonary tuberculosis, presented with spontaneous left pneumothorax. A pigtail chest drain was unfortunately inserted into his left upper lobe. Parts of his left lung were tethered to the visceral pleura secondary to previous tuberculosis. A second pigtail catheter was therefore carefully placed under CT guidance. The original chest drain was removed. The patient deteriorated rapidly with worsening hypoxia and rapidly expanding surgical emphysema to his right arm and face. A largebore chest drain was inserted to drain the pleural space which stabilised his condition. We performed balloon occlusion under direct bronchoscopic visualisation whilst observing the rate of airleak at the underwater seal, and detected 2 segments responsible for the airleak. In the interest of time, we decided to trial autologous blood injection into these segments, whilst waiting for endobronchial valves (our preferred technique) to arrive. We injected 15 mls of patients blood into both segments. At the same time, we performed blood pleurodesis by injection 100 mls of patients blood into the pleural space. We did not use talc in view of patients frailty and poor pulmonary reserve. The airleak gradually ceased and the drains were removed within 6 days. Conclusion Bronchopleural stula may result from lung resection, lung abscess, malignancy, or direct injury such as chest drain insertion. Many methods have been used to aid closure of bronchopleural stulae, but there is yet no consensus or guidelines on patient selection or preferred technique. In many cases, both the bronchopleural stula and pleural space need to be managed. Blood pleurodesis has been described in many reports. The possible mechanisms include patch of the airleak, an inammatory response or low grade intrapleural infection. The most frequent complication is empyema. Tension pneumothorax has been reported due to blood clot in the chest drain. In summary, we describe a case of iatrogenic bronchopleural stula successfully managed by obstruction with endobronchial autologous blood clot and autologous blood patch pleurodesis.

SLEEP RELATED BREATHING DISORDERS AND LUNG FUNCTION IN PATIENTS WITH OCULOPHARYNGODISTAL MYOPATHY UFUK MEMIS, ESEN KIYAN, HACER DURMUS, PIRAYE OFLAZER 25 Aralik Devlet Hastanesi Gogus Hast, Fevzi Cakmak Bulvari Sehitkamil Gaziantep, Turkey Introduction To evaluate sleep related breathing disorders (SRBD) in patients with Oculopharyngodistal myopathy (OPDM) and their relationship with pulmonary functions. Methods Arterial blood gases analysis, spirometry, diaphragm function (sitting supine FVC% change), respiratory muscle strength (PImax, PEmax, SNIP and PCF-peak cough ow), Epworth sleepiness scale (ESS), Pittsburgh sleep quality index (PSQI) and polysomnographic (PSG) ndings were analyzed in 24 OPDM patients. Results There were widespread involvement (oculopharyngodistal) in 58.3% of patients (seven female and 17 male, age 33.2 12.6 years). Most of the patients (83.3%) had at least one of snoring, apnea and excessive daytime sleepiness. Hypoxemia (PaO2 < 80 mmHg) in 25% patients, hypercapnia (PaCO2 > 45 mmHg) in 37.5% were detected and 50% had a restrictive pattern (FVC < 80%). Respiratory muscle strength was reduced (PImax = 69.3 28.3 cmH2O, PEmax = 75.3 33.7 cmH2O, SNIP = 72.7 14.8 cmH2O, PCF 353.1 112.8 L/min). Diaphragm was affected in 41.7% of the patients (FVC% change 10%). Of patients 70.8% had, sleep related hypoxemia/hypoventilation syndrome, 54.2% obstructive sleep apnea (OSA) and 33.3% OSA syndrome. Sleep related events occurred mostly at REM period. Lung functions and a lot of nocturnal parameters were strongly correlated. Lung functions and SRBD were worse in patients with widespread involvement and long disease duration. ESS and PSQI were insufcient to predict SDRB. Nocturnal BIPAP were planned in 66.7% of patients because of SRBD. Conclusion This study showed that SRBDs common in OPDM patients and lung functions can predict these problems. Sleep related respiratory problems and lung functions deteriorates with prolonged disease duration and widespread muscle involvement. Thats why lung functions must be routine in OPDM patients and PSG indications must be decided according to lung function.

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A CASE REPORT OF SECONDARY AMYLOIDOSIS WITH LOCALIZED PULMONARY AMYLOIDOSIS GONENC ORTAKOYLU, AYSE BAHADIR, FIGEN ALKAN, EMEL CAGLAR, ERCAN KORUCU, LEVENT DALAR Yedikule Chest Hospital, Istanbul, Turkey Introduction Localized pulmonary amyloidosis is dened as amyloid deposition isolated to the respiratory tract and does not include amyloidosis associated with systemic deposition (primary, secondary, or familial). Methods A 58-year-old female was admitted to the hospital with complaints of productive cough, fatigue and breathlessness. There was in her past medical history she had undergone bilaterally total thyroidectomy 15 months earlier due to papiller thyroid carcinoma. Chest X-ray showed reticulonodular inltrates bilateral middle zones. Results Fiberoptic bronchoscopy revealed polypoid lesions at the distal trachea, at the right main bronchus, at the orice of the bronchus of the right and left upper lobe. Bronchial mucosae was fragile and tends to bronchial hemorrhage. Polypoid lesions were extirpated by rigid bronchoscopy and a biopsy specimen was positive for amyloid after staining with Congo red. Conclusion The incidence of pulmonary amyloidosis associated with secondary amyloidosis is low. Patients may be asymptomatic or may have dyspnea, hemoptysis, recurrent pneumonia, cough, or atelectasis. Management has included observation, intermittent bronchoscopic resection, and surgical resection.

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THE IMPACT OF SNORING ON THE SEVERITY OF OBSTRUCTIVE SLEEP APNEA YASSER AL KASSAR1, YASER ABU EL SAMEED1, JAISHEN RAJAH2, MSALAM SARA3, GAIL WADDLETON4, WAGIH DJAZMATI1 1 Department of Medicine, Sheikh Khalifa Medical City, UAE, 2Department of Pediatrics, Sheikh Khalifa Medical City, UAE, 3Intensive Care, Sheikh Khalifa Medical City, UAE, and 4College of the North Atlantic, Qatar Introduction Snoring is commonly present in Obstructive Sleep Apnea (OSA). The objective of this study is to see if there is correlation between the degree of snoring and the severity of OSA. Other variable were also studied including age, gender and Body Mass Index (BMI). Methods We reviewed all adult patients polysomnograms done between 2007 and 2009 in the Sleep Lab of Sheik Khalifa Medical City in Abu Dhabi, UAE. Snoring was scored based on the snoring-detection microphone attached to the patients neck. It was graded 1-to-3, 3 being the loudest. We used Multiple regression analysis for the age, gender, BMI and the severity of OSA. The median AHI and the Inter Quartile Ratio (IQR) were calculated for each grade of snoring severity. Results A total of 406 sleep studies were reviewed. We excluded normal and titration polysomnograms. In the remaining 216 diagnostic studies with conrmed OSA the median Apnea Hypopnea Index (AHI) was 20 (IQR: 952). The median age was 52 years (IQR: 4060). AHI increased steadily with advancing age (P = 0.008) (correlation coefcient r = 0.178). 139 (64%) of patients were male. The median AHI for males and females was 36 and 33, respectively. This was not statistically different (P = 0.52). The median BMI was 37 (ranged 1777). Patients were divided into two groups according to BMI: less than 30 and more than 30. Median AHI for BMI less than 30 was 13 (IQR 828) and was 23 (IQR = 1057) for BMI above 30. AHI was signicantly higher in the group with BMI >30 (P = 0.001) (r = 0.266). Snoring was documented in 98% of the patients. The median AHI and IQR for snoring grade 1, 2, and 3 were 16.8 (IQR 7.930), 19.8 (IQR 9.746), and 27.7 (IQR 12.959), respectively (see gure). Using ANOVA, there was no statistically signicant difference between the AHI and the snoring severity (P = 0.276).

THE USE OF BERLIN QUESTIONNAIRE VERSUS STOP QUESTIONNAIRE AS SCREENING TOOL AMONG FILIPINO PATIENTS UNDERGOING CORONARY ARTERY BYPASS SURGERY AT RISK FOR OBSTRUCTIVE SLEEP APNEA MITZI BANATE, JOSEPH HOPE CAL, AILEEN GUZMAN-BANZON, MA ENCARNITA BLANCO-LIMPIN, TERESITA S DE GUIA, FERNANDO G AYUYAO, LILY LAO Division of Pulmonary and Critical Care Medicine, Philippine Heart Center, Quezon City, Philippines Introduction Obstructive sleep apnea (OSA) is a common disorder that is often undiagnosed in many patients including a number who require surgery. Obstructive sleep apnea is strongly associated with risk for perioperative complications. Approximately, 8090% of patients with obstructive sleep apnea were initially undiagnosed. Two internationally validated questionnaires were used as a screening tools in identifying surgical patients at risk for obstructive sleep apnea and these are the Berlin questionnaire and the STOP questionnaire. Methods This paper is used as a clinical evaluation tool in identifying patients at risk for having obstructive sleep apnea in our institution. All patients who met the inclusion criteria were screened by the two screening tools: Berlin questionnaire and STOP questionnaire. Patients admitted for elective coronary artery bypass surgery underwent preoperative evaluation using the two questionnaires. The questionnaires were administered by the researcher through interview. Results A total of 54 patients were enrolled in the study, 47 (87%) male and 7 (13%) female were included. The mean age of the subjects was 57 9.5 (SD) and the mean neck circumference was 39.4 2.7 (SD). Majority of the subjects 81.5% (n = 44) have co-morbidity of hypertension. Base on the analysis of our data, only the presence of increasing BMI (p value = 0.042) and neck circumference (p value = 0.041) in the high risk group (Berlin category) were found to have statically signicant result. None of the aforementioned factors were identied among high risk group as categorize by STOP screening tool. The only identied risk factor among high risk group in both Berlin and STOP questionnaire is the presence of hypertension (p value = 0.004 and 0.00, respectively) identied among patients. Conclusion Both the Berlin and STOP questionnaire can identify patients as high or low risk of probable obstructive sleep apnea and their computed statistical agreement (p value = 0.00) was signicant.

Conclusion Our study showed that high degree of snoring was not associated with increasing severity of OSA. Increasing BMI and age were directly correlated with increasing severity of OSA. Snoring score may not be a useful predictor for the severity of OSA.

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CORRELATION BETWEEN EXCESSIVE DAYTIME SLEEPINESS AND THE RISK FOR OBSTRUCTIVE SLEEP APNEA WITH ACADEMIC PERFORMANCE AMONG MEDICAL STUDENTS MA PHILINA PABLO, MARY JANE SANDAGON, MANUEL JORGE Section of Pulmonary Medicine, Philippine General Hospital, Taft Avenue, Manila, Philippines Introduction Various studies describes an excessive occurrence of daytime somnolence in occupations. Despite the importance of these facts, little is to be found in the literature regarding excessive daytime sleepiness in medical students and its academic consequences. This study is the rst in the Philippines to study the possible correlation between excessive daytime sleepiness, risk for obstructive sleep apnea and academic achievements among medical students. Methods This is a cohort study involving enrolled students at the UP College of Medicine. A self-administered validated questionnaire consisting of Prole, Sleeping habits, Berlin Assessment Questionnaire, and the Epworth Sleepiness Scale, was distributed to the subjects. The general weighted average of students at the end of the 2nd semester school year 2010 was obtained and correlation between ESS scores and grades and of risk of OSA with grades were determined. Results There were a total of 458 (64.4%) students who participated in the study. About 75.9% had abnormal daytime sleepiness (mild to excessive). First year students mostly had normal levels of daytime sleepiness while the rest of the year levels had mostly moderate levels of daytime sleepiness (ranging from 35.2 to 43.7%). There was poor correlation between levels of daytime sleepiness (measured by ESS) and academic performance (measured by grades) respectively (Pearsons correlation coefcient 0.0139). There was also poor correlation between risk for Obstructive Sleep Apnea as measured by the Berlin Questionnaire and grades of students (Pearsons correlation coefcient 0.063). This is consistent with previous studies showing that there were no negative effects in the performance of medical students who have little sleep. Conclusion Excessive daytime sleepiness is of moderate levels among year level 2 to 6 medical students while year level 1 students mostly had normal daytime sleepiness levels. There was poor correlation between the level of sleepiness and risk for OSA with academic performance.

EVALUATION OF THE RELATIONSHIP OF THE FREQUENCY SCALE OF SYMPTOMS FOR GASTROESOPHAGEAL REFLUX DISEASE AND AIRFLOW LIMITATION BY NEP METHOD IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA SYNDROME KAZUHISA URUSHIHATA, KAYOKO IKEGAWA, NOBUMITSU KOBAYASHI, MASAYUKI HANAOKA, KEISHI KUBO The First Department of Internal Medicine, Shinshu University School of Medicine, Asahi 3-1-1, Matsumoto, Nagano-prefecture, Japan Introduction Increased upper airways collapsibility has been implicated in the pathogeny of obstructive sleep apnea syndrome (OSAS). And there is a high prevalence of gastroesophageal reux disease (GERD) in patients with OSAS. It is thought that increased respiratory efforts in OSAS patients generate more negative intrathoracic pressure, contributing to reux of gastric acids. In this study, we evaluated the relationship of the symptoms of GERD in patients with OSAS, using the questionnaire, the frequency scale of symptoms for gastroesophageal reux disease (FSSG), which is widely used in Japan. And we examined airow limitations by applying negative expiratory pressure (NEP) method. Methods 43 patients with OSAS were recruited. There were 28 patients of them, who have been treated with continuous positive airway pressure (CPAP), and the 15 other patients, who had not been treated. And we recruited 10 subjects as control group, in which apnea-hypopnea index was lower than 5/h by polysomnography data, or who had no episodes with snoring. All subjects responded to the FSSG. And spirometry and NEP methods of 4 cmH2O were performed in seated potion. 50%VT ratio was dened as the ratio of the expiratory ow with negative pressure (4 cmH2O) and the expiratory ow at rest in the 50 point of the tidal volume. Results 1) The score of FSSG was signicantly higher in OSAS patients than the control group. In addition, signicant inverse correlations were observed between AHI and the score of FSSG in OSAS group. 2) There were more patients who showed ow-limitation in negative expiratory pressure in OSAS group, than control group. In OSAS group, inverse correlations were observed between AHI and 50%VT ratio. 3) In OSAS group, positive correlations were observed between 50%VT ratio and the score of FSSG. Conclusion In this study, the inverse correlation between the score of FSSG and AHI was found. It is thought that severe OSAS patients has less complaints about using CPAP, and better adherence might be shown. So it is thought that in severe OSAS patients, the symptoms of GERD could be improved easily, by using CPAP. And It may be thought that the collapsibility of upper respiratory tract by moderate negative pressure could help preventing the esophageal reux.

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ANALYSIS OF GENE EXPRESSION PROFILES OF PERIPHERAL BLOOD B LYMPHOCYTES IN VARIOUS CLINICAL PHENOTYPES OF ASTHMA NOR EZLEEN QISTINA, ROSLAN HARUN, ROOHAIDA OTHMAN Institute of Medical Science Technology, Kuala Lumpur University, Malaysia Introduction B lymphocytes play important roles in the inammatory response in asthma including IgE production, antigen presentation and secretion of certain cytokines. However the exact molecular pathways are still largely unknown. The objectives of this study were to identify gene expression proles of peripheral blood B lymphocytes and subsequently determine gene signatures that were associated with different clinical phenotypes of asthma. In addition we aimed to identify biological processes and pathways involved in the molecular mechanisms of asthma. Methods Peripheral blood B cells were isolated from subjects with different manifestations of asthma: mild (n = 8), moderate controlled (n = 8), moderate uncontrolled (n = 10), severe steroid dependant (n = 7), severe steroid resistant (n = 7) and normal control (n = 8). Total RNA were extracted from the B lymphocytes, reverse transcribed and amplied linearly before being labelled and hybridized on Illumina HumanRef-8 Expression BeadChips that had 24,355 elements. Microarray data was analysed using GeneSpring GX 10.0.02 software and real-time PCR was performed to validate the microarray gene expression. Results Data were analysed according to several conditions including asthma control status, steroid response, asthma severity and disease status. Differential gene analyses, corrected for multiple testing, revealed 7 (p < 0.001), 307 (p < 0.001), 52 (p < 0.01) and 40 (p < 0.05) genes that were differentially expressed in each condition respectively. Those genes were found to be involved in various biological processes including T lymphocyte and mast cell activation, cytoskeleton actin regulation, Notch pathway and guanylate cyclase pathway when analysed using the gene set enrichment analysis (GSEA). Several gene signatures like CCT6A, TUBGCP3, RARRES2, PSIP1 and SLC38A6 that were found to be associated with asthma control status and response to steroid. Conclusion These ndings may provide new insight in the mechanisms of airway inammation in asthma.
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HRCT FINDINGS IN INDIVIDUALS WITH ENVIRONMENTAL EXPOSURE TO ASBESTOS IN KOREA KIHYUN SEO, YONGHOON KIM, SUNGSHICK JOU, EUNCHEOL JANG, YONGBAE KIM, YONGJIN LEE, CHANHO PARK Soonchunhyang University Cheonan Hospital, 23-20 Bongmyung-dong, South Korea Introduction Most studies on asbestos-related diseases are based on chest radiographs. The aim of this study was to investigate parenchymal and pleural lesions of persons exposed to environmental asbestos diagnosed by HRCT scan. Methods A large screening programme including the chest radiographs and HRCT examinations was organized from 2008 to 2009 in Korea for formerly asbestos-exposed persons. We performed the chest radiographs of 4057 patients who were present inhabitants of villages where asbestos mines had been within 1 km. Among them, HRCT scans of 849 patients with abnormal lesions on chest radiograph were obtained. Results 263 cases (6.5%) presented pleural plaques most likely related to asbestos exposure (bilateral parietal, diaphragmatic or mediastinal pleural plaque) on chest radiographs. Parenchymal changes with pleural plaques on HRCT scans that could be considered as asbestosis were visible in 180 cases (21.0%) and non-specic interstitial brosis not related to asbestos was noted in 333 cases (38.8%). One strongly suspicious lung cancer and six cases of histologically proven lung cancer plus ve patients of active tuberculosis were found by HRCT scans. Conclusion Our ndings indicate that HRCT can play a central role in differentiating parenchymal diseases of certain formerly asbestos-exposed persons who have obscure chest radiographs and may be useful for diagnosing a suspicious nding on a chest radiograph.

PD 1503

PREVALENCE AND PROFILE OF SMOKERS, PERCEPTIONS ON SMOKING, AND PRACTICES ON SMOKING CESSATION AMONG MEDICAL STUDENTS, RESIDENTS, AND FELLOWS IN TRAINING AT THE PHILIPPINE GENERAL HOSPITAL KATRINA ANGELA REYES, MARIA PHILINA PABLO, LENORA FERNANDEZ Section of Pulmonary Medicine, Philippine General Hospital, Taft Avenue, Manila, Philippines Introduction In a study done at the Philippine General Hospital last 2003, the prevalence of smoking among physicians was even higher than that of the general population at 48%. It was also observed that physicians who smoke tend to provide less motivation or even completely neglect to give advise regarding smoking cessation. Methods A representative population of medical students, clerks, interns, residents, and fellows in UPCM-PGH for the month of February 2010 were identied by stratied random sampling and given a questionnaire consisting of 21 items. The z test was used to determine if there was a signicant difference between the prevalence obtained from this study and that done in 2003. The chi-square test was used to determine if there was a signicant difference between smokers and non-smokers in their perceptions on smoking and practices on smoking cessation. Results There were 228 respondents. The prevalence of smoking among medical students, residents, and fellows in UPCM-PGH has declined signicantly from 48% to 28% since 2003 but remains high relative to developed countries. A better understanding of the factors that motivate physicians to smoke may help us explain the high prevalence despite access to information on its harmful effects. Medical students and physicians who smoke tend to be more permissive and tolerant of smoking but both smokers and non-smokers believe that this habit indirectly encourages patients to smoke. Majority believe that it is the moral obligation of doctors to initiate smoking cessation measures but only a minority consistently give advice on smoking cessation and an even a smaller percentage offer pharmacologic therapy and enrollment to smoking cessation programs. The main reasons why doctors fail to do so are their smoking status and the feeling that they have inadequate knowledge or skill in helping patients quit smoking. Conclusion Physicians must be reminded of their roles as exemplars, and the no smoking policy in UPCM-PGH must be strictly implemented. Knowledge and skills on smoking cessation must be incorporated earlier in the medical curriculum specically so that physicians may develop the condence to counsel patients and to offer them the appropriate smoking cessation method.

LIVING KNOWLEDGE OF THE HEALING PLANTS: ETHNO-PHYTOTHERAPY IN THE RURAL COMMUNITIES FROM THE TUNGIPARA UPAZILA OF GOPALGANJ DISTRICT IN BANGLADESH MOHAMMAD ARIFUL HAQUE MOLLIK Helena Centre (3rd Floor), House No. 95, New Eskaton Road, Dhaka, Bangladesh Introduction Plant materials are being used from time immemorial as one of the main sources of medicine to combat various diseases. Tungipara Upazila is one of the less studied regions of Gopalganj district in Bangladesh for its ethnopharmacological values. The present paper synthesizes the rst report related to the documentation and conservation of ethnopharmacological plants in the Tungipara Upazila and their socio-economic relationship with the forests and its resources. Methods Ethnopharmacological data were collected using semi-structured interviews, eld observations, preference, and direct matrix ranking with the traditional medicinal practitioners. Parts of the plants used, dosages, and the mode of drug administrations in different ailments are described. All plant samples were collected and identied at the Bangladesh National Herbarium. Results First-hand information about twenty-nine plants belonging to twentynine genera and twenty-two botanical families were recorded during extensive eld surveys carried in the Tungipara Upazila of Gopalganj district in Bangladesh; which are therapeutically used against different diseases such as coughs, colds, fevers, dysentery, diarrhea, ulcers, asthma, male and female weakness, tuberculosis, snake-bite, and skin disorders are covered in this report. The plant families included Gesneriaceae Dumortier, Acanthaceae Juss., Linaceae S.F. Gray, Ranunculaceae Juss., Agaricaceae Fr., Oleaceae Hoffmgg. & Link, Santalaceae R.Br., Malvaceae Juss., Convolvulaceae Juss., Papaveraceae Juss., Solanaceae Juss., Rosaceae Juss., Sapindaceae Juss., Asteraceae Bercht. & J. Presl, Meliaceae Juss., Zingiberaceae Martinov, Fabaceae Lindl., Musaceae Juss., Arecaceae Schultz-Schultzenstein, Amaranthaceae Juss., Labiatae Juss., and Araceae Juss.. It was noted in this ethnopharmacological survey that the rural communities were quite satised with treatment by the traditional medicinal practitioners. Conclusion Documenting the eroding plants and associated indigenous knowledge can be used as a basis for developing management plans for conservation and sustainable use of plants in the area. It is expected that scientic studies conducted with the plants can lead to discovery of novel drugs.

Journal Compilation 2010 Asian Pacic Society of Respirology