Diagnosis Of Chronic Respiratory Diseases Research Articles

Using spirometry for screening and diagnosis of chronic respiratory diseases in primary health care: findings from a community health project in rural India

Background Chronic respiratory diseases (CRDs) such as Chronic obstructive pulmonary disease (COPD), Asthma and post-tuberculosis lung disease (PTLD) are a growing public health concern in India. Early diagnosis and management of CRDs require a good quality spirometry test, a technician to conduct spirometry and a chest physician to interpret the results. In India, these are not available at the primary care level. This study reports the feasibility of a large-scale CRD diagnosis and management program in primary care using a unique point-of-care spirometry solution, Briota PFT in a Box™. # Methods A community-based cross-sectional study was conducted among 15,602 adults in Dindori Taluka (subdivision), Nashik, Maharashtra state. This study was part of a holistic CRD diagnosis and management program SAVE™ (Spirometry Assisted Virtually Early). Make In India point of care solution Briota PFT in a Box™ was used. A House‐to‐house community-based assessment checklist (CBAC) survey, 4-parameter spirometry test, 15-parameter pre and post-bronchodilator spirometry test and a software-assisted medical examination by the medical officer at primary care were conducted. Software was used to generate CRD diagnosis and lung health score (LHS™). The diagnosis was verified by the chest physician. Confirmed diagnosed patients were provided treatment and offered a patient support program. Interviews were conducted with the patients, nurses, doctors and public health officials for understanding feasibility and documenting learning from program SAVE™. # Results Out of 15,602 adults surveyed, total 4,937 (31.6%) were identified as “CRD high risk”. 1231 participants based on medical examination, spirometry tests and software analysis were identified as CRD candidates by medical officers at primary care. 1154 participants out of 15,602 (7.4%) were confirmed diagnosed as CRD patients post independent evaluation by chest physicians. At the time of follow-up, 537 patients (75% of 712 patients enrolled in patient support program) reported improvement in symptoms and high satisfaction with the program. District health officer, Medical officers, nurses, Accredited Social Health Activist (ASHA) from the primary health care centers confirmed ease of use and feasibility of using Briota PFT in a Box™ in program SAVE™. Outcome and learning from program SAVE™ was documented and submitted to Ministry of Health and Family Welfare Government of India. # Conclusions CRD diagnosis and management in large scale settings in primary healthcare level using a point of care spirometry solution Briota PFT in a Box™ is highly feasible.

Implementation of a screening and management pathway for chronic obstructive pulmonary disease in patients with atrial fibrillation.

Chronic obstructive pulmonary disease (COPD) negatively impacts the efficacy of heart rhythm control treatments in patients with atrial fibrillation (AF). Although COPD is recognized as a risk factor for AF, practical guidance about how and when to screen for COPD is not available. Herein, we describe the implementation of an integrated screening and management pathway for COPD into the existing pre-ablation work-up in an AF outpatient clinic infrastructure. Consecutive unselected patients accepted for AF catheter ablation in the Maastricht University Medical Center+ were prospectively screened for airflow limitation using handheld (micro)spirometry at the pre-ablation outpatient clinic supervised by an AF nurse. Patients with results suggestive of airflow limitation were offered referral to the pulmonologist. Handheld (micro)spirometry was performed in 232 AF patients, which provided interpretable results in 206 (88.8%) patients. Airflow limitation was observed in 47 patients (20.3%). Out of these 47 patients, 29 (62%) opted for referral to the pulmonologist. The primary reason for non-referral was low perceived symptom burden. Using this screening strategy 17 (out of 232; 7.3%) ultimately received a diagnosis of chronic respiratory disease, either COPD or asthma. A COPD care pathway can successfully be embedded in an existing AF outpatient clinic infrastructure, using (micro)spirometry and remote analysis of results. Although one out of five patients had results suggestive of an underlying chronic respiratory disease, only 62% of these patients opted for a referral. Pre-selection of patients as well as patient education might increase the diagnostic yield and requires further research.

Implementation of a screening and management pathway for chronic obstructive pulmonary disease in patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Chronic obstructive pulmonary disease (COPD) is a well-recognized risk factor for atrial fibrillation (AF) and negatively impacts symptom burden and AF rhythm control treatment. Nevertheless, there are currently no guideline recommendations or practical guides about whether or not and how to screen for COPD. Purpose To describe the implementation of an integrated screening and management pathway for COPD in patients with diagnosed AF, into the existing pre-ablation work-up embedded in an AF outpatient clinic infrastructure. Methods Unselected consecutive AF patients scheduled for catheter ablation were prospectively screened for airflow limitation using handheld (micro)spirometry devices. Patients with a forced expiratory volume (FEV) in one second (FEV1)/FEV in six seconds ratio of ≤0.73 or a FEV1/forced vital capacity ratio of <0.70, depending on the device, were offered referral to a pulmonologist. The COPD assessment test (CAT) (eight items scoring symptoms such as dyspnoea and coughing on a scale of 0-5) was applied to evaluate perceived disease burden, whereas the Respiratory Health Screening Questionnaire (RHSQ) (ten items scoring age, smoking, body mass index and respiratory symptoms) was evaluated as an additional screening tool. The COPD screening and management pathway consisted of six steps: 1) patient education about COPD, 2) handheld (micro)spirometry under supervision of a specialized AF nurse, 3) review of diagnostic results, 4) telephone consultation with the patient in case of results suggestive of airflow limitation, 5) referral if opted by patient and 6) full pulmonary function testing and consultation with a pulmonologist (Figure 1). Results In total, 232 patients (median age 66 [59-71], 31.9% female, 33.6% self-reported dyspnoea) were included in this screening and management pathway. Screening (micro)spirometry yielded interpretable results in 88.8% of patients. Airflow limitation was observed in 47 patients (20.3%) of whom 29 (12.5%) opted for referral to the pulmonologist and 17 (7.3%) received a final diagnosis of chronic respiratory disease, either COPD or asthma (11 newly diagnosed). The majority of these 17 patients (70.6%) scored high on the CAT (score ≥10), whereas 14 (82.4%) had a moderate-to-highly increased risk of COPD based on the RHSQ (score ≥16.5). Conclusions A COPD care pathway can successfully be embedded in an existing AF patient clinic infrastructure, using (micro)spirometry and remote analysis of results. Although all patients chose to perform handheld (micro)spirometry, only 60% of those in whom referral was advised opted for referral. Preselection of patients based on respiratory symptoms as well as increasing patient involvement might increase patient acceptance for respiratory analysis, and requires further research.

A strategy for improvement in diagnosis and treatment of bronchial asthma in primary care

Recently, bronchial asthma is considered as a heterogeneous disease characterized by chronic airway inflammation and respiratory symptoms, which vary in time and intensity and manifest together with variable obstruction of the airways. Asthma is one of the most common chronic respiratory diseases in primary care. Patients with certain respiratory symptoms seek for medical aid initially in primary care physicians, such as therapeutists, general practitioners, and family physicians, who can suspect and diagnose chronic respiratory diseases such as bronchial asthma, chronic obstructive pulmonary disease (COPD), allergic rhinitis, etc. Currently, untimely diagnosis of asthma and late initiation of anti-inflammatory treatment are widespread, mainly due to insufficient knowledge of primary care physicians on diagnostic criteria and therapeutic standards for asthma. Feasible and convenient algorithms for asthma diagnosis and treatment in primary care were developed by experts of Russian Respiratory Society and Russian Association of Allergologists and Clinical Immunologists. A therapeutic algorithm for asthma treatment in primary care institutions uses an approach considering symptom severity both in patients with newly diagnosed and previously treated for asthma. Diagnostic tools, such as a questionnaire for asthma diagnosis and an algorithm for differential diagnosis between asthma and COPD are mainly intended to facilitate diagnosis of chronic respiratory disease, particularly bronchial asthma, by a primary care physician and to improve the healthcare quality for these patients.

How to unveil chronic respiratory diseases in clinical practice? A model of alliance between general practitioners and pulmonologists

IntroductionAsthma and COPD are under-diagnosed and undertreated in adult populations, mainly due to the discrepancy between guideline recommendations and clinicians' practices. One of the reasons of this discrepancy is the difficulty encountered in real life in sharing the management of chronic respiratory diseases between general practitioners (GPs) and respiratory physicians. MethodsAn explorative, population-based investigation was performed to test whether, and to what extent, an active collaboration between GPs and pulmonologists increases the diagnosis and proper treatment of chronic obstructive airway diseases. The "COPD action" involved an in-house intervention by pulmonologists who trained GPs on how to diagnose the disease and interpret the spirometry, yielding a final agreed diagnosis. ResultsA total of 210 subjects (M/F: 156/54; age: 62.5 ± 13.8, mean ± SD) were consecutively invited by 20 GPs and classified in a) healthy, b) symptomatic with no airway obstruction, and 3) affected by chronic respiratory diseases. 11% of previously defined "healthy" subjects were diagnosed with COPD, and symptomatic subjects were diagnosed with asthma (20%) or COPD (23%). In addition, in those who already carried a diagnosis of chronic respiratory diseases as judged by GPs, the diagnosis of COPD decreased significantly after respiratory specialist intervention (p = 0.001), in favor of asthma and chronic bronchitis. Furthermore, following the clinical and lung function assessments performed by the respiratory physicians, changes in inhaled treatments were statistically significant for each therapeutic category (test-retest reliability: r = 0.42; p < 0.001). ConclusionIn conclusion, the collaboration between GPs and pulmonologists based on a pro-active approach to the individuals attending the primary care offices followed by an in-house intervention by specialists may largely improve the diagnosis and management of chronic respiratory diseases.

The AIMAR recommendations for early diagnosis of chronic obstructive respiratory disease based on the WHO/GARD model*.

Respiratory diseases in Italy already now represent an emergency (they are the 3rd ranking cause of death in the world, and the 2nd if Lung cancer is included). In countries similar to our own, they result as the principal cause for a visit to the general practitioner (GP) and the second main cause after injury for recourse to Emergency Care. Their frequency is probably higher than estimated (given that respiratory diseases are currently underdiagnosed). The trend is towards a further increase due to epidemiologic and demographic factors (foremost amongst which are the widespread diffusion of cigarette smoking, the increasing mean age of the general population, immigration, and pollution). Within the more general problem of chronic disease care, chronic respiratory diseases (CRDs) constitute one of the four national priorities in that they represent an important burden for society in terms of mortality, invalidity, and direct healthcare costs. The strategy suggested by the World Health Organization (WHO) is an integrated approach consisting of three goals: inform about health, reduce risk exposure, improve patient care. The three goals are translated into practice in the three areas of prevention (1-primary, 2-secondary, 3-tertiary) as: 1) actions of primary (universal) prevention targeted at the general population with the aim to control the causes of disease, and actions of Predictive Medicine - again addressing the general population but aimed at measuring the individual’s risk for disease insurgence; 2) actions of early diagnosis targeted at groups or - more precisely - subgroups identified as at risk; 3) continuous improvement and integration of care and rehabilitation support - destined at the greatest possible number of patients, at all stages of disease severity. In Italy, COPD care is generally still inadequate. Existing guidelines, institutional and non-institutional, are inadequately implemented: the international guidelines are not always adaptable to the Italian context; the document of the Agency for Regional Healthcare Services (AGE.NA.S) is a more suited compendium for consultation, and the recent joint statement on integrated COPD management of the three major Italian scientific Associations in the respiratory area together with the contribution of a Society of General Medicine deals prevalently with some critical issues (appropriateness of diagnosis, pharmacological treatment, rehabilitation, continuing care); also the document “Care Continuity: Chronic Obstructive Pulmonary Disease (COPD)” of the Global Alliance against chronic Respiratory Diseases (GARD)-Italy does not treat in depth the issue of early diagnosis. The present document – produced by the AIMAR (Interdisciplinary Association for Research in Lung Disease) Task Force for early diagnosis of chronic respiratory disease based on the WHO/GARD model and on available evidence and expertise –after a general examination of the main epidemiologic aspects, proposes to integrate the above-mentioned existing documents. In particular: a) it formally indicates on the basis of the available evidence the modalities and the instruments necessary for carrying out secondary prevention at the primary care level (a pro-active,‘case-finding’approach; assessment of the individual’s level of risk of COPD; use of short questionnaires for an initial screening based on symptoms; use of simple spirometry for the second level of screening); b) it identifies possible ways of including these activities within primary care practice; c) it places early diagnosis within the “systemic”, consequential management of chronic respiratory diseases, which will be briefly described with the aid of schemes taken from the Italian and international reference documents.

The AIMAR recommendations for early diagnosis of chronic obstructive respiratory disease based on the WHO/GARD model*

&#x0D; &#x0D; &#x0D; &#x0D; Respiratory diseases in Italy already now represent an emergency (they are the 3rd ranking cause of death in the world, and the 2nd if Lung cancer is included). In countries similar to our own, they result as the principal cause for a visit to the general practitioner (GP) and the second main cause after injury for recourse to Emergency Care. Their frequency is probably higher than estimated (given that respiratory diseases are currently underdiagnosed). The trend is towards a further increase due to epidemiologic and demographic factors (foremost amongst which are the widespread diffusion of cigarette smoking, the increasing mean age of the general population, immigration, and pollution). Within the more general problem of chronic disease care, chronic respiratory diseases (CRDs) constitute one of the four national priorities in that they represent an important burden for society in terms of mortality, invalidity, and direct healthcare costs. The strategy suggested by the World Health Organization (WHO) is an integrated approach consisting of three goals: inform about health, reduce risk exposure, improve patient care. The three goals are translated into practice in the three areas of prevention (1-primary, 2-secondary, 3-tertiary) as:1) actions of primary (universal) prevention targeted at the general population with the aim to control the causesof disease, and actions of Predictive Medicine - again addressing the general population but aimed at measuring the individual’s risk for disease insurgence; 2) actions of early diagnosis targeted at groups or - more precisely - subgroups identified as at risk; 3) continuous improvement and integration of care and rehabilitation support - destined at the greatest possible number of patients, at all stages of disease severity. In Italy, COPD care is generally still inadequate. Existing guidelines, institutional and non-institutional, are inadequately implemented: the international guidelines are not always adaptable to the Italian context; the document of the Agency for Regional Healthcare Services (AGE.NA.S) is a more suited compendium for consultation, and the recent joint statement on integrated COPD management of the three major Italian scientific Associations in the respiratory area together with the contribution of a Society of General Medicine deals prevalently with some critical issues (appropriateness of diagnosis, pharmacological treatment, rehabilitation, continuing care); also the document “Care Continuity: Chronic Obstructive Pulmonary Disease (COPD)” of the Global Alliance against chronic Respiratory Diseases (GARD)-Italy does not treat in depth the issue of early diagnosis. The present document – produced by the AIMAR (Interdisciplinary Association for Research in Lung Disease) Task Force for early diagnosis of chronic respiratory disease based on the WHO/GARD model and on available evidence and expertise –after a general examination of the main epidemiologic aspects, proposes to integrate the above-mentioned existing documents. In particular: a) it formally indicates on the basis of the available evidence the modalities and the instruments necessary for carrying out secondary prevention at the primary care level (a pro-active,‘case-finding’approach; assessment of the individual’s level of risk of COPD; use of short questionnaires for an initial screening based on symptoms; use of simple spirometry for the second level of screening); b) it identifies possible ways of including these activities within primary care practice; c) it places early diagnosis within the “systemic”, consequential management of chronic respiratory diseases, which will be briefly described with the aid of schemes taken from the Italian and international reference documents.&#x0D; &#x0D; &#x0D; &#x0D;

Predictors of Clinical Success Among a National Veterans Affairs Cohort With Methicillin-Resistant Staphylococcus aureus Pneumonia

BackgroundThe treatment of methicillin-resistant Staphylococcus aureus (MRSA) pneumonia is exceedingly complicated, which is concerning because of the high mortality rate associated with the infection. Identification of independent predictors of clinical success can optimize patient care by assisting clinicians in treatment decisions. ObjectivesOur goal was to identify independent predictors of clinical success in a national Veterans Affairs (VA) cohort of patients with MRSA pneumonia. MethodsA nested case-control study was conducted among a cohort of VA patients with MRSA pneumonia receiving linezolid or vancomycin between January 2002 and September 2010. Cases included those demonstrating clinical success, defined as discharge from the hospital or intensive care unit by day 14 after treatment initiation, in the absence of death, therapy change, or intubation by day 14. Control subjects represented nonsuccess, defined as therapy change, intubation, intensive care unit admission, readmission, or death between treatment initiation and day 14. The potential predictors assessed included treatment, patient demographic and admission characteristics, previous health care and medication exposures, comorbidities, and medical history. Odds ratios (ORs) and 95% CIs were calculated from logistic regression. ResultsOur study included 2442 cases of clinical success and 1290 control subjects. Demographic characteristics varied between the clinical success and nonsuccess groups, including age, race, and region of facility. A current diagnosis of chronic respiratory disease (46% vs 42%) and diagnosis of pneumonia in the year before the MRSA pneumonia admission (37% vs 32%) were both more common in the clinical success group. Despite these significant differences, only 2 predictors of clinical success were identified in our study: previous complication of an implant or graft, including mechanical complications and infections, in the year before the MRSA pneumonia admission (adjusted OR, 1.55 [95% CI, 1.17–2.06]) and treatment with linezolid (adjusted OR, 1.53 [95% CI, 1.12–2.10]). Predictors of nonsuccess (adjusted OR [95% CI) included diagnosis of concomitant urinary tract infection (0.82 [0.70–0.96]), intravenous line (0.76 [0.66–0.89]), previous coagulopathy (0.74 [0.56–0.96]), previous amputation procedure (0.72 [0.53–0.98]), current coagulopathy diagnosis (0.71 [0.53–0.96]), dialysis (0.54 [0.38–0.76]), multiple inpatient procedures (0.53 [0.45–0.62]), inpatient surgery (0.48 [0.41–0.57]), and previous endocarditis (0.24 [0.07–0.81]). ConclusionsMRSA pneumonia tends to affect patients with complex care, and identification of the predictors of clinical success is useful when considering different therapeutic approaches. In this national cohort of VA patients with MRSA pneumonia, treatment was the only modifiable variable predicting clinical success.

Automatic pulmonary fissure detection and lobe segmentation in CT chest images.

BackgroundMulti-detector Computed Tomography has become an invaluable tool for the diagnosis of chronic respiratory diseases. Based on CT images, the automatic algorithm to detect the fissures and divide the lung into five lobes will help regionally quantify, amongst others, the lung density, texture, airway and, blood vessel structures, ventilation and perfusion.MethodsSagittal adaptive fissure scanning based on the sparseness of the vessels and bronchi is employed to localize the potential fissure region. Following a Hessian matrix based line enhancement filter in the coronal slice, the shortest path is determined by means of Uniform Cost Search. Implicit surface fitting based on Radial Basis Functions is used to extract the fissure surface for lobe segmentation. By three implicit fissure surface functions, the lung is divided into five lobes. The proposed algorithm is tested by 14 datasets. The accuracy is evaluated by the mean (±S.D.), root mean square, and the maximum of the shortest Euclidian distance from the manually-defined fissure surface to that extracted by the algorithm.ResultsAveraged over all datasets, the mean (±S.D.), root mean square, and the maximum of the shortest Euclidian distance are 2.05 ± 1.80, 2.46 and 7.34 mm for the right oblique fissure. The measures are 2.77 ± 2.12, 3.13 and 7.75 mm for the right horizontal fissure, 2.31 ± 1.76, 3.25 and 6.83 mm for the left oblique fissure. The fissure detection works for the data with a small lung nodule nearby the fissure and a small lung subpleural nodule. The volume and emphysema index of each lobe can be calculated. The algorithm is very fast, e.g., to finish the fissure detection and fissure extension for the dataset with 320 slices only takes around 50 seconds.ConclusionsThe sagittal adaptive fissure scanning can localize the potential fissure regions quickly. After the potential region is enhanced by a Hessian based line enhancement filter, Uniform Cost Search can extract the fissures successfully in 2D. Surface fitting is able to obtain three implicit surface functions for each dataset. The current algorithm shows good accuracy, robustness and speed, may help locate the lesions into each lobe and analyze them regionally.

Educational and supportive interventions for improving adherence to inhalation therapy in people with chronic respiratory diseases: A systematic review protocol

Review question/objective The objective of this systematic review is to identify the best available research evidence related to the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy in people with chronic respiratory diseases, focusing on measures of adherence and health outcomes. The specific review questions to be addressed are: 1. What is the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy in terms of inhalation regimens and inhalation techniques in people with chronic respiratory diseases? 2. What is the effectiveness of educational and supportive interventions for improving adherence to inhalation therapy on health service utilization and patient outcomes including symptoms, pulmonary function, and quality of life? 3. What is the effectiveness of various designs, in terms of components, modes and intensities, of educational and supportive interventions for improving adherence to inhalation therapy? Inclusion criteria Types of participants This review will consider studies that include adults aged 18 or above, with a clinical diagnosis of chronic respiratory disease and prescribed self-administered inhalation therapy as a long term regular treatment, irrespective of the type of inhaler used. For the purposes of this review, "chronic respiratory diseases" is defined by WHO in 2007 as "the chronic diseases of the airways and other structures of the lung" (p.5). 1 Inhalation therapy is defined as "a treatment in which a substance is administered to the respiratory tract with inspired air". 6 This review will focus on inhalation of drugs. Those studies with prescribed administration of oxygen and water will be excluded. There is no universal standard for how long a treatment is undertaken to be defined as a "long term treatment". Acute episodic drug treatments, such as a course of antibiotics, will be excluded. Types of interventions of interest All educational interventions, with or without supportive programs, designed to improve the chronic respiratory disease sufferers inhalation technique and adherence to their prescribed inhalation therapy will be considered. Those studies that involve comparison of different types of inhalation medications, inhaler devices or inhalation methods to improve the adherence to inhalation therapy will be excluded. For the TRUNCATED AT 350 WORDS

Executive summary of the multicenter survey on the prevalence and risk factors of chronic respiratory diseases in patients presenting to primary care centers and emergency rooms in Syria.

In 2009-2010, Tishreen University and the Health Ministry conducted a multi-center Survey on the Prevalence and risk factors of chronic respiratory diseases (CRD) and co-morbidities in patients presenting to primary care centers, general outpatients clinics and Emergency rooms in hospitals. In collaboration with WHO-Global alliance against chronic respiratory diseases (GARD), www.who.int/gard , the protocol of this survey has been established tested and validated by the WHO-GARD experts (1). This survey is the first multi-center survey on CRD in primary care in the Eastern Mediterranean Region. The strongest point is the use of lung function measurement for diagnosis of CRD (2).

Utilization of the National Health and Nutrition Examination (NHANES) Survey for Symptoms, Tests, and Diagnosis of Chronic Respiratory Diseases and Assessment of Second hand Smoke Exposure.

Respiratory diseases encompass a number of complex disorders that constitute a major cause of both morbidity and mortality worldwide with a major burden to the afflicted as well as the health care systems that care for them. Although the prevalence of chronic respiratory diseases (CRDs) has been decreasing in industrialized countries due to a decreasing number of smokers and stricter laws aimed at reducing exposure to secondhand smoke (SHS), the burden of CRDs in developing world populations is expected to worsen due to communicable disease prevention programs, aging populations, environmental air pollution, and continued tobacco smoke exposure. Although tobacco smoking has been shown to be significantly associated with many CRDs, evidence linking SHS exposure to different CRDs is mixed, especially with low levels of SHS exposure. The National Health and Nutrition Examination Survey (NHANES) is a series of studies designed to assess the health and nutritional status of non-institutionalized adults and children in the United States (U.S.). In addition to being used to monitor the health of the U.S. population, NHANES data allow for research into prevalent health problems and their risk factors in the population, such with CRDs and SHS exposure. NHANES data can be utilized to explore a variety of issues related to the assessment of SHS exposure and its association to respiratory symptoms and illnesses. First, we provide a brief review of NHANES including its strengths and limitations. We then provide a summary of the variables and publically available population based data that can be used to study associations between SHS exposure and CRD symptoms, testing and diagnoses. Rich and cost effective, NHANES data provide a unique opportunity for research into the risk factors for CRDs in the U.S. population, particularly into the possible health effects of low levels of SHS exposure.

Chronic respiratory disease and multimorbidity: Prevalence and impact in a general practice setting

Multimorbidity is defined as two or more co-existing chronic conditions in an individual and is common in general practice. It is associated with poorer outcomes for patients. This study aimed to establish the prevalence of multimorbidity in patients with chronic respiratory disease in general practice and to describe its impact on health service use. Cross-sectional study based in general practice in Dublin. Drug and disease code searches were performed to identify adult patients with a diagnosis of chronic respiratory disease. Medical records were reviewed for chronic respiratory diagnosis, other chronic conditions, demographic characteristics, General Practitioner (GP) and practice nurse utilisation rates, and numbers of medications. In a general practice population of 16,946 patients 3.9% had chronic respiratory disease and 60% of these had one or more co-existing chronic condition(s). GP and practice nurse utilisation rates, and number of medications were significantly higher among those with multimorbidity compared with those with respiratory disease alone. Multivariate analysis showed that increasing age and low socio-economic status were significantly associated with multimorbidity. The majority of patients with chronic respiratory disease have multimorbidity. Clinical guidelines based on single disease entities and outcomes are not as easy to implement and may not be as effective in this group.

Chronic Respiratory Disease (Crd) of Chicken

Chronic respiratory disease (CRD) of chicken is the most costly disease confronting poultry industries in the world. The economic losses due to CRD was estimated up to billions rupiahs per year in Indonesia, and in the USA was estimated up to hundred millions dollars per year. The losses mainly due to decreases of body weight gain, egg production, feed efficiencies, hatchabilities and increases of embryo mortality. The main causative agent of CRD is Mycoplasma gallisepticum (MG). Respiratory disturbances, excretion of nasal exudate, coughing, sneezing and hyperaemic of the conjunctiva are very often seen as the clinical signs. Pathological lesions are often found as inflammation of respiratory organs and more specific lesions are seen as inflammation and thickening of the airsac membranes with foci cheesy materials scattered around the airsacs. Diagnosis of CRD can be made by clinical symptoms, serology examination dan isolation of MG. Treatment, prevention and controls of CRD have been carried out for years, but cases of CRD are still present up to now. The MGTS11 vaccine as the third generation of CRD vaccine was reported to be effective for controlling CRD of chickens and potentially used as a tool for eradication programme of CRD in the future. Key words: Chronic respiratory disease, chicken

Nitric oxide as a biomarker of allergic inflammation in children

The aim of this study was to analyze clinical importance of exhaled nitric oxide (NOex) measurement for early detection, differential diagnosis and control of treatment of chronic respiratory pathology in children. The study involved 412 children of 5 to 18 years old with different chronic bronchopulmonary diseases. Apart from a typical clinical, laboratory, and instrumental diagnostic methods, NOex was measured in all the children using the chemiluminescent gas analyzer 280i (Sievers, USA). The control group included 30 healthy children aged 5 to 18 with mean NOex 14.8 ± 1.4 ррb (9.2 ÷ 21.4 ррb). The majority of asthmatic children had high NOex (&gt; 20 ppb in 284 (90 %) asthmatic children), р &lt; 0.01, both in stable asthma and exacerbation. The NOex level was directly correlated to the severity and period of the disease (frequency of asthma attacks, time from the last asthma attack, lung function parameters), and blood levels of allergic markers (eosinophils, total IgE, circulating immune complexes, IL-4). Therefore, NOex monitoring was useful in evaluating the efficacy of different treatment modes. In other chronic respiratory diseases, NOex level was also elevated but to lesser degree. In children with primary ciliary dyskinesia, NOex was significantly below the normal level that could be used as a preliminary screening tool. In conclusion, NOex measurement is a reliable and objective method to control allergic inflammation in the airways. It is of great clinical importance and is helpful in differential diagnosis of chronic respiratory diseases and confirmation of the diagnosis. It allows individual choice of therapy, control of the patient's adherence to treatment and prognosis of future exacerbations.

International Primary Care Respiratory Group (IPCRG) Guidelines: Diagnosis of respiratory diseases in primary care

This Diagnosis paper constitutes the second of the IPCRG Guideline papers on the management of chronic respiratory diseases in primary care. Primary care health professionals are usually the first point of contact for patients who can present a wide range of initial symptoms which may or may not constitute their first presentation of a chronic disease such as asthma, COPD, or rhinitis. This paper is focussed upon the early identification and diagnosis of chronic respiratory diseases in primary care. It uses a symptom-based approach, and includes original questionnaires and diagnostic guides to help the primary care clinician proceed systematically through the diagnostic process.

Severe bilateral panlobular emphysema and pulmonary arterial hypoplasia: Unusual manifestations of Menkes disease

Menkes disease is an X-linked recessive disorder of copper transport characterized by neurological deterioration, connective tissue, and vascular defects, abnormal hair, and death in early childhood. We report on a patient with Menkes disease in whom severe diffuse emphysema caused respiratory failure and death at 14 months of age. He had severe growth and developmental delays and other typical clinical manifestations of Menkes disease. He developed respiratory problems requiring continuous supplemental oxygen and a progressively enlarging soft tissue mass appeared on the neck. Imaging studies revealed cystic spaces in multiple lobes of the lung consistent with bullous emphysema. The neck mass was determined to be an internal jugular venous aneurysm. At autopsy, extensive emphysematous change was evident. Post-mortem barium injections of the pulmonary arterial system revealed marked dilatation and tortuosity of the preacinar pulmonary arteries and reduced numbers of intra-acinar arteries. Severe emphysema, presumably caused by abnormal elastin due to deficiency of the copper-dependent enzyme lysyl oxidase, may represent an underestimated clinical complication of Menkes disease and should be considered in the differential diagnosis of chronic respiratory disease in these patients.

Chronic respiratory disease morbidity in construction workers: patterns and prognostic significance for permanent disability and overall mortality

The aim of this study was to determine chronic respiratory disease morbidity in construction workers, and to assess the prognostic value of various morbidity measures on permanent disability and on all-cause mortality. Subjects in this analysis were male employees in the German construction industry, aged 40-64 yrs, who were examined by the occupational health service between August 1986 and December 1988. Prevalence of respiratory disorders as characterized by: 1) pathological findings on lung auscultation; 2) reduced forced expiratory volume in one second (FEV1); and 3) a medical diagnosis of chronic respiratory disease (International Classification of Diseases 9th revision (ICD-9) 490496) was assessed among occupational groups of construction workers, and compared with prevalence among white-collar employees. Active follow-up was conducted between October 1992 and July 1994 to ascertain working and life status (completeness: 92 and 96%, respectively). The prognostic value of the morbidity measures on permanent disability and on all-cause mortality was assessed using the Cox proportional hazards model. In the entire cohort, crude prevalence was 7.6% for pathological findings on lung auscultation, 8.8% for a reduced FEV1 (<70% of predicted value), and 6.1% for a recorded diagnosis of chronic respiratory disease. There was strong variation of prevalence with age, smoking status and, less clearly, occupation. The relative risk for permanent disability varied between 1.9 and 3.2, and for mortality between 2.0 and 2.9, respectively, when men with the various measures of bronchopulmonary disorders were compared with other men. The morbidity measures utilized allow the identification of employees at higher risk of disability and death, and this may facilitate targeting of specific prevention and rehabilitation measures.

Prevalence and diagnosis of chronic respiratory symptoms in adults.

To investigate the prevalence and diagnosis of chronic respiratory disease in adults. Screening questionnaire was sent to all patients aged 40-70 on the register of a group general practice; those responding positively were sent a detailed questionnaire and invited for assessment of respiratory function by forced expiratory volume in one second, forced vital capacity, peak flow rate, and reversibility studies with a beta adrenergic inhaler. Group general practice in south west London. Of 2387 patients aged 40-70, 1444 completed a screening questionnaire. Of the 509 patients who reported cough, phlegm, wheeze, or shortness of breath, 324 responded to a detailed questionnaire, 256 of whom had simple respiratory function assessed. Chronic bronchitis affected 106 (17%) men and 58 (7%) women, and wheeze occurring at least once a week affected 60 (9%) men and 20 (3%) women. Only a half to a third of patients had received a diagnostic label of chronic bronchitis or asthma for their symptoms. There was considerable clinical and physiological similarity (including reversibility of the airways) between patients labelled as having asthma and having chronic bronchitis. A label of asthma was used more often for patients of social classes I and II. Comparison with prevalence surveys carried out in the 1950s showed that respiratory symptoms are as common now as then, but the risk of disabling chronic bronchitis has fallen, more among men than women, probably because of their reduced smoking. Changes in diagnostic fashion, together with increased detection, may have contributed to the upward trend in reported morbidity from asthma over the past 30 years.

Thallium acetate in the diagnosis of chronic respiratory disease of chickens.

Thallium acetate in the diagnosis of chronic respiratory disease of chickens.