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Khoo SM, Tan LK, Said N, Lim TK. Metered-dose inhaler with spacer instead of nebulizer during the outbreak of severe acute respiratory syndrome in Singapore. Respir Care 2009; 54:855-60. [PMID: 19558736 DOI: 10.4187/002013209793800411] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The use of metered-dose inhaler (MDI) with spacer instead of nebulizer may be important during an outbreak of an airborne infection. However, there is a paucity of data on patients' and nurses' abilities and perspectives on MDI with spacer for the treatment of acute airway obstruction during such an outbreak. METHODS We evaluated 50 consecutive MDI-with-spacer treatments administered in the respiratory wards of the National University Hospital of Singapore, and interviewed the patients after each treatment during the outbreak of severe acute respiratory syndrome (SARS). We also conducted interviews with 50 nurses who had experience in administering bronchodilators via both nebulizer and MDI with spacer. RESULTS Forty-six patients (92%) were able to use MDI with spacer effectively. Sixteen percent of the patients preferred nebulizer over MDI with spacer. Fifty-eight percent of the patients thought MDI with spacer was easier to use than nebulizer, and 34% thought MDI was as easy to use as nebulizer. Sixteen percent of the patients thought that nebulizer was more effective than MDI with spacer in relieving their symptoms. Ninety-six percent of the nurses preferred nebulizer over MDI with spacer. Forty-two nurses (84%) thought that nebulizer was more effective for treating acute airflow obstruction in the hospital. CONCLUSIONS In the in-patient setting during an outbreak of an airborne infection, for treatment of acute airflow obstruction, MDI with spacer was acceptable and preferred by a high percentage of patients. However, a high percentage of nurses had misconceptions regarding the efficacy of and patients' ability to use MDI with spacer.
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Phua J, See KC, Chan YH, Widjaja LS, Aung NW, Ngerng WJ, Lim TK. Validation and clinical implications of the IDSA/ATS minor criteria for severe community-acquired pneumonia. Thorax 2009; 64:598-603. [DOI: 10.1136/thx.2009.113795] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Lim TK. Primary versus reactivated TB. Int J Tuberc Lung Dis 2009; 13:418. [PMID: 19275809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
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Khoo SM, Lim TK. Effects of inhaled versus systemic corticosteroids on exhaled nitric oxide in severe acute asthma. Respir Med 2008; 103:614-20. [PMID: 19022641 DOI: 10.1016/j.rmed.2008.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 10/08/2008] [Accepted: 10/10/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND There is a paucity of information on the differential effects of systemic versus inhaled corticosteroids on airway inflammation in patients with acute asthma. This study aimed to evaluate the effects of stopping systemic corticosteroids while maintaining the inhaled corticosteroids (ICS) on airway inflammation, lung function and asthma symptoms in patients who had been discharged from hospital after treatment for severe acute asthma. METHODS Twenty-four adult patients with severe exacerbations of asthma were treated with both oral and inhaled corticosteroids after discharge from hospital. Oral corticosteroids were stopped after 1 week. Spirometry, asthma quality of life questionnaire (AQLQ) score and exhaled nitric oxide (NO) were measured at discharge, 1 week, and 2 weeks after discharge. RESULTS Withdrawal of oral corticosteroids resulted in significant rebound in mean exhaled NO by 11.0ppb (95% CI, 4.9-17.1ppb, p<0.001) or 47.7% (95% CI, 22.4-73.1%) despite uninterrupted ICS treatment. The rebound in exhaled NO occurred despite significant improvement in the mean AQLQ score (p=0.006) and frequency of reliever use (p=0.003) and was not associated with significant change in the mean FEV(1) (p=0.64). CONCLUSIONS In patients discharged from hospital after treatment for asthma exacerbations, withdrawal of oral corticosteroids resulted in increase in exhaled NO levels despite continued ICS treatment.
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Lim TK, Cherian J, Poh KL, Leong TY. The rapid diagnosis of smear‐negative pulmonary tuberculosis: A cost‐effectiveness analysis. Respirology 2008. [DOI: 10.1111/j.1440-1843.2000.00284.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Chong CF, Khoo KL, Lim TK, Chang AY, Lim HL, Lee CN, Wong PS. Comparison of clinical with pathological nodal staging from systematic mediastinal lymph node dissection in early resectable non-small cell lung cancer. Singapore Med J 2007; 48:620-4. [PMID: 17609822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
INTRODUCTION We compared the accuracy of clinical nodal (cN) status N0-1 with that of pathological nodal (pN) status obtained from systematic mediastinal lymph node dissection (SMLD) in primary non-small cell lung cancer. METHODS Data from 22 consecutive patients, who underwent lung cancer resection and SMLD of at least three mediastinal lymph node stations, from November 2001 to May 2003, were ana1ysed retrospectively. Only patients with cN0-1 status on computed tomography (CT) referred for surgery, were included in this study. RESULTS Mean age of patients was 66.6 +/- 8.1 years with a male to female ratio of 17:5. Mean number of lymph node stations dissected was 5.8 +/- 1.8. 41 percent had squamous cell carcinoma, 45.5 percent had adenocarcinoma, and 4.5 percent each had large cell carcinoma, bronchioalveolar carcinoma or a lymphoepithelial carcinoma. pN2 metastases were found in 27.3 percent of patients. The sensitivity of cN0-1 was only 12.5 percent, with a specificity of 92.9 percent and an area under the receiver operating characteristics curve of 0.53. The positive and negative predictive values of cN0-1 status were 50 percent and 65 percent, respectively, with an accuracy of 59 percent. 41 percent of patients were understaged with 27.3 percent in pathological stage III. Curative resections were achieved in 59 percent of patients. CONCLUSION The sensitivity of cN0-1 status based on CT alone is extremely poor when compared with pN status from SMLD. Based on cN0-1 status alone without SMLD, 27.3 percent of patients in pN2 would have been understaged. We recommend that all patients with cN0-1 status should undergo SMLD of at least three appropriate mediastinal node stations, for more accurate staging.
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Phua J, Lim TK. Use of traditional versus electronic medical-information resources by residents and interns. MEDICAL TEACHER 2007; 29:400-2. [PMID: 17786760 DOI: 10.1080/01421590701477456] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND Little is known about the information-seeking behaviour of junior doctors, with regard to their use of traditional versus electronic sources of information. AIMS To evaluate the amount of time junior doctors spent using various medical-information resources and how useful they perceived these resources to be. METHODS A questionnaire study of all residents and interns in a tertiary teaching hospital in July and August 2004. RESULTS In total, 134 doctors returned the completed questionnaires (response rate 79.8%). They spent the most time using traditional resources like teaching sessions and print textbooks, rating them as most useful. However, electronic resources like MEDLINE, UpToDate, and online review articles also ranked highly. Original research articles were less popular. CONCLUSION Residents and interns prefer traditional sources of medical information. Meanwhile, though some electronic resources are rated highly, more work is required to remove the barriers to evidence-based medicine.
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Phua J, Koay ESC, Zhang D, Tai LK, Boo XL, Lim KC, Lim TK. Soluble triggering receptor expressed on myeloid cells-1 in acute respiratory infections. Eur Respir J 2006; 28:695-702. [PMID: 16837506 DOI: 10.1183/09031936.06.00005606] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Levels of the soluble form of the triggering receptor expressed on myeloid cells (sTREM)-1 are elevated in severe sepsis. However, it is not known whether sTREM-1 measurements can distinguish milder bacterial infections from noninfectious inflammation. The present authors studied whether serum sTREM-1 levels differ in community-acquired pneumonia, exacerbations of chronic obstructive pulmonary disease (COPD), asthma and controls, and whether sTREM-1 may be used as a surrogate marker for the need for antibiotics. Serum sTREM-1 levels in 150 patients with pneumonia, COPD and asthma exacerbations and 62 healthy controls were measured. Serum sTREM-1 levels were significantly elevated in pneumonia (median 295.2 ng x mL(-1)), COPD (280.3 ng x mL(-1)) and asthma exacerbations (184.0 ng x mL(-1)) compared with controls (83.1 ng x mL(-1)). Levels were higher in pneumonia and Anthonisen type 1 COPD exacerbations than in type 2 and 3 COPD and asthma exacerbations. The area under the receiver operating characteristics curve for sTREM-1 as a surrogate marker for the need for antibiotics was 0.77. Serum levels of the soluble form of the triggering receptor expressed on myeloid cells-1 were elevated predominantly in pneumonia and Anthonisen type 1 COPD exacerbations versus type 2 and 3 chronic obstructive pulmonary disease exacerbations, asthma and controls. Serum levels of the soluble form of the triggering receptor expressed on myeloid cells-1 has moderate but insufficient accuracy as a surrogate marker for the need for antibiotics in lower respiratory tract infections.
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Sun YJ, Lim TK, Ong AKY, Ho BCH, Seah GT, Paton NI. Tuberculosis associated with Mycobacterium tuberculosis Beijing and non-Beijing genotypes: a clinical and immunological comparison. BMC Infect Dis 2006; 6:105. [PMID: 16820066 PMCID: PMC1552074 DOI: 10.1186/1471-2334-6-105] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 07/05/2006] [Indexed: 11/11/2022] Open
Abstract
Background The Mycobacterium tuberculosis Beijing genotype is biologically different from other genotypes. We aimed to clinically and immunologically compare human tuberculosis caused by Beijing and non-Beijing strains. Methods Pulmonary tuberculosis patients were prospectively enrolled and grouped by their M. tuberculosis genotypes. The clinical features, plasma cytokine levels, and cytokine gene expression levels in peripheral blood mononuclear cells (PBMC) were compared between the patients in Beijing and non-Beijing groups. Results Patients in the Beijing group were characterized by significantly lower frequency of fever (odds ratio, 0.12, p = 0.008) and pulmonary cavitation (odds ratio, 0.2, p = 0.049). Night sweats were also significantly less frequent by univariate analysis, and the duration of cough prior to diagnosis was longer in Beijing compared to non-Beijing groups (medians, 60 versus 30 days, p = 0.048). The plasma and gene expression levels of interferon (IFN) γ and interleukin (IL)-18 were similar in the two groups. However, patients in the non-Beijing group had significantly increased IL-4 gene expression (p = 0.018) and lower IFN-γ : IL-4 cDNA copy number ratios (p = 0.01). Conclusion Patients with tuberculosis caused by Beijing strains appear to be less symptomatic than those who have disease caused by other strains. Th1 immune responses are similar in patients infected with Beijing and non-Beijing strains, but non-Beijing strains activate more Th2 immune responses compared with Beijing strains, as evidenced by increased IL-4 expression.
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Mukhopadhyay A, Guan M, Chen HY, Lu Y, Lim TK. Prospective study of a new serological test (ASSURE TB Rapid Test) for the diagnosis of pulmonary tuberculosis. Int J Tuberc Lung Dis 2006; 10:620-4. [PMID: 16776448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
OBJECTIVE To prospectively compare a rapid tuberculosis serological test, ASSURE TB Rapid Test, with traditional smear and culture methods for the diagnosis of pulmonary tuberculosis (PTB). DESIGN All consecutive in-patients aged > or = 18 years suspected of having active PTB and admitted between June 2001 and March 2003 were tested with three sputum samples for smear and culture of Mycobacterium tuberculosis and serology (done within 3 days). RESULTS Of 238 patients initially enrolled (male: female 2.5:1, mean age 56.6 years), the final analysis included 216 patients. For the final diagnosis of PTB, the sensitivity and specificity of the serological test were respectively 60.2% (95%CI 50.5-69.1) and 82.3% (95%CI 74.2-88.2) compared to 53.4% (95%CI 43.8-62.7) and 98.2% (95%CI 93.8-99.5) for the smear test. A combination of smear and serology provided an increased sensitivity of 74.8% (95%CI 65.6-82.2), but a lower specificity of 80.5% (95%CI 72.3-86.8). CONCLUSION The new serological test showed a moderate increase in sensitivity but a decrease in specificity compared to smear examination. The combination (smear + serology) test further increased the sensitivity while maintaining a moderate specificity.
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Lim DL, Ma S, Wang XS, Cutter J, Chew SK, Lim TK, Lee BW. Trends in sales of inhaled corticosteroids and asthma outcomes in Singapore. Thorax 2006; 61:362-3. [PMID: 16565269 PMCID: PMC2104622 DOI: 10.1136/thx.2005.050435] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Khoo KL, Ho KY, Nilsson B, Lim TK. EUS-guided FNA immediately after unrevealing transbronchial needle aspiration in the evaluation of mediastinal lymphadenopathy: a prospective study. Gastrointest Endosc 2006; 63:215-20. [PMID: 16427923 DOI: 10.1016/j.gie.2005.06.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2005] [Accepted: 06/08/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transbronchial needle aspiration (TBNA) and EUS-guided FNA (EUS-FNA) are minimally invasive diagnostic approaches to mediastinal lymphadenopathy. Rapid on-site cytopathologic evaluation (ROSE) may facilitate the decision whether to proceed to a second procedure in the same session. The aim of this study was to determine the utility of TBNA with ROSE, combined with the option for immediate EUS-FNA in a single-session approach to mediastinal lymphadenopathy. METHODS We prospectively recruited 20 patients (12 men; mean age 66.7 +/- 10.2 years) with mediastinal lymphadenopathy on CT who required cytopathologic evaluation. Bronchoscopy was first performed with TBNA and ROSE. If this was unrevealing, EUS-FNA was performed immediately afterward with ROSE. All procedures were performed with the patient under local anesthesia and sedation. RESULTS TBNA specimens were deemed adequate on-site in 13 patients, and EUS-FNA was performed in the remaining 7 patients. TBNA with ROSE was falsely negative in one patient. The diagnostic yield for TBNA and EUS-FNA alone was 65% and 86%, respectively. This single-session approach provided a yield of 90%, with no complications. The final diagnoses were 12 non-small-cell lung cancer, two small-cell lung cancer, one metastatic adenocarcinoma, two sarcoidosis, one tuberculosis, one lymphoma, and one with no definitive diagnosis. CONCLUSIONS Combining TBNA with the option for EUS-FNA immediately after unrevealing TBNA gave a yield approaching that of mediastinoscopy and, therefore, may reduce the need for invasive mediastinal sampling. This single-session endoscopic approach was safe, required only local anesthesia and sedation, was convenient, and obviated the need for patients to return for a second procedure.
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Khoo KL, Leng PH, Ibrahim IB, Lim TK. The changing face of healthcare worker perceptions on powered air-purifying respirators during the SARS outbreak. Respirology 2005; 10:107-10. [PMID: 15691247 PMCID: PMC7169158 DOI: 10.1111/j.1440-1843.2005.00634.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Before the advent of severe acute respiratory syndrome (SARS), use of the powered air-purifying respirator (PAPR) in the setting of pulmonary tuberculosis has been controversial. Data regarding health care worker (HCW) perceptions and problems encountered with the use of the PAPRs were lacking. METHODOLOGY A questionnaire-based survey was conducted of HCWs who had used the PAPR in clinical practice during the SARS outbreak, when use of the PAPR was mandatory and widespread. Evaluations of the question of whether HCWs were receptive to the use of the PAPR and their perceptions of common problems that were encountered were made. Perceptions of comfort, ease of use, visual, hearing, breathing and speech impairment, perceived protection against SARS and usage preferences were recorded. RESULTS Only a minority of respondents found the PAPR uncomfortable, despite some interference with communication. Despite its much higher cost, the majority (84%) preferred to use the PAPR rather than the N-95 respirator when treating suspected SARS patients. However, opinions were equally divided regarding its use when treating patients with pulmonary tuberculosis; with 51% being in favour. CONCLUSIONS With the advent of highly contagious diseases that pose a major occupational hazard to HCWs, the use of the PAPR has become more acceptable in clinical practice.
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Lim TK. Lessons in case management for the physician. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2005; 34:339-40. [PMID: 16021222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
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Phua J, Kong K, Lee KH, Shen L, Lim TK. Noninvasive ventilation in hypercapnic acute respiratory failure due to chronic obstructive pulmonary disease vs. other conditions: effectiveness and predictors of failure. Intensive Care Med 2005; 31:533-9. [PMID: 15742175 DOI: 10.1007/s00134-005-2582-8] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2004] [Accepted: 02/03/2005] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study compared the effectiveness of noninvasive ventilation (NIV) and the risk factors for NIV failure in hypercapnic acute respiratory failure (ARF) due to chronic obstructive pulmonary disease (COPD) vs. non-COPD conditions. DESIGN AND SETTING Prospective cohort study in the medical intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS 111 patients with hypercapnic ARF, 43 of whom had COPD exacerbations and 68 other conditions. Baseline characteristics of the two groups were similar. MEASUREMENTS AND RESULTS The risk of NIV failure, defined as the need for endotracheal intubation, was significantly lower in COPD than in other conditions (19% vs. 47%). High APACHE II score was an independent predictor of NIV failure in COPD (OR 5.38 per 5 points). The presence of pneumonia (OR 5.63), high APACHE II score (OR 2.59 per 5 points), rapid heart rate (OR 1.22 per 5 beats/min), and high PaCO(2) 1 h after NIV (OR 1.22 per 5 mmHg) were independent predictors of NIV failure in the non-COPD group. Failure of NIV independently predicted mortality (OR 10.53). CONCLUSIONS Noninvasive ventilation was more effective in preventing endotracheal intubation in hypercapnic ARF due to COPD than non-COPD conditions. High APACHE II score predicted NIV failure in both groups. Noninvasive ventilation was least effective in patients with hypercapnic ARF due to pneumonia.
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Mukhopadhyay A, Lim TK. A prospective audit of referrals for breathlessness in patients hospitalised for other reasons. Singapore Med J 2005; 46:21-4. [PMID: 15633004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
INTRODUCTION This prospective audit examines the diagnostic and clinical outcomes of consecutive adult inpatients who were admitted to a university hospital for other reasons and referred for breathlessness to respiratory physicians. METHODS We enrolled all adult inpatients referred for breathlessness from May 2000 to October 2001. We evaluated the clinical features and utility of routine investigations, such as blood tests and radiology. Subsequent investigations were undertaken at the discretion of the physician. RESULTS Of the 105 patients, 49 were men and 56 were women. Their mean age was 66 plus or minus 18 years. Surgical departments and cardiology were the main referring departments. Respiratory infection (31 percent) was the most common diagnosis. Acute pulmonary embolism (PE) was diagnosed in four patients postoperatively. Chest radiographs were helpful in making a diagnosis in 66 percent of patients. Computed tomography pulmonary angiogram of the thorax was performed in 31 of the 34 patients who were investigated for acute PE. More postoperative than non-postoperative patients were tested for PE (p-value less than 0.0001). CONCLUSION In hospitalised patients referred for breathlessness, respiratory infections were the most common diagnosis and the chest radiograph was the most useful initial investigation. Computed tomography pulmonary angiogram was the preferred investigation for acute PE and clinicians were more inclined to investigate for PE in postoperative patients.
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Khoo KL, Lim TK. Pulmonary hypereosinophilia. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2004; 33:521-3. [PMID: 15329768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
INTRODUCTION Eosinophilic lung diseases are a diverse group of pulmonary disorders linked by the common finding of increased eosinophilia in blood and/or tissue. They usually present to the clinician as pulmonary infiltrates with eosinophilia for which the differential diagnoses is fairly broad. CLINICAL PICTURE Three patients presented with subacute cough, pulmonary infiltrates and a markedly elevated eosinophil count >1.5 x 109/L. Each case exemplifies its clinical peculiarities and pearls and illustrates the diversity in this group of disorders. TREATMENT A common theme in the approach to its management is excluding infection before proceeding with therapy, often with steroids. OUTCOME There is often a dramatic response to steroid therapy with resolution of symptoms and chest radiographic findings. CONCLUSION The arbitrary label of "pulmonary hypereosinophilia" enables the differential diagnoses to be narrowed to the 4 main categories of infections with parasites or fungus, the Churg-Strauss syndrome, chronic eosinophilic pneumonia and the idiopathic hypereosinophilic syndrome.
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Lim TK. Geminal operators and symmetric requirements. Mol Phys 2004. [DOI: 10.1080/00268970310001658130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Khoo KL, Chua GSW, Mukhopadhyay A, Lim TK. Transbronchial needle aspiration: initial experience in routine diagnostic bronchoscopy. Respir Med 2003; 97:1200-4. [PMID: 14635974 DOI: 10.1016/s0954-6111(03)00230-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Transbronchial needle aspiration (TBNA) has been shown to be useful not only for the diagnosis and staging of lung cancer, its most widely studied indication, but also for many of other clinical indications. Despite this, it remains largely underutilized, mainly because of concerns with poor yield, safety, lack of experience of the bronchoscopist, and lack of cytopathological support. OBJECTIVE To study the clinical utility and yield of TBNA as an adjunct to other conventional procedures in diagnostic bronchoscopy at a centre that was relatively inexperienced with this technique, but where there was availability of rapid on-site evaluation (ROSE). Most of the major indications for TBNA in both malignant as well as benign disease were included. SETTING University Teaching Hospital naïve to the procedure. PATIENT AND METHODS Forty-five consecutive patients who underwent TBNA as part of diagnostic bronchoscopy during a 2-year study period. RESULTS TBNA gave a yield of 65% for evaluation of mediastinal disease, both benign and malignant. The overall diagnostic utility for all indications was 71% and there were no complications. CONCLUSIONS We conclude that TBNA is a useful and safe adjunct to diagnostic bronchoscopy in routine clinical practice. It has a satisfactory yield even with an inexperienced team, if used with ROSE.
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Abstract
The coronavirus that causes severe acute respiratory syndrome (SARS) is transmitted mainly via respiratory droplets. Typical presenting symptoms are akin to those of ordinary pneumonia. Young patients start with fever, chills, malaise, headache, or myalgia; cough and dyspnoea follow. Older persons and those taking corticosteroids may have neither fever nor respiratory symptoms. Exceptional suspicion is needed to identify SARS early in the illness. During an outbreak, even patients with low suspicion of SARS should be promptly isolated, and all contacts quarantined. Health workers need training in the use of appropriate barriers against droplets and other body fluids. Any fever cluster in patients or carers requires immediate action: discharges, visits, and transfers between wards and hospitals should be stopped. Halting hospital admissions and ten-day quarantine of suspected cases create wide buffer zones. To counter a possible resurgence of SARS, a system of prepared isolation and quarantine facilities is important.
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Lim TK, Mukhopadhyay A, Gough A, Khoo KL, Khoo SM, Lee KH, Kumarasinghe G. Role of clinical judgment in the application of a nucleic acid amplification test for the rapid diagnosis of pulmonary tuberculosis. Chest 2003; 124:902-8. [PMID: 12970015 DOI: 10.1378/chest.124.3.902] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Several nucleic acid amplification (NAA) tests for Mycobacterium tuberculosis (MTB) have been licensed for the rapid diagnosis of active pulmonary tuberculosis (PTB) in respiratory secretions. There is uncertainty however regarding the practical application of these tests in clinical decision making. OBJECTIVE To evaluate the utility of the COBAS AMPLICOR assay (Roche Diagnostics; Singapore) for MTB as applied by specialists for the rapid diagnosis of PTB in the routine clinical setting. DESIGN A prospective study of consecutive patients suspected of PTB and tested with the AMPLICOR assay under the care of respiratory physicians. The final diagnosis was based on all relevant clinical information after at least 3 months of follow-up. Accuracy of the NAA test was compared with that of the initial expectant treatment. Expectant treatment was based on an integrated approach that incorporated clinical evaluation with results of direct smear and NAA tests. RESULTS The incidence of PTB in 168 patients was 32%. The basis for expectant treatment of PTB was positive smear result in 47%, clinical suspicion in 26%, and positive AMPLICOR result in 23%. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the AMPLICOR test were 77%, 100%, 99%, 90%, and 93%, respectively. In comparison, they were 96%, 97%, 94%, 98%, and 97%, respectively, for the integrated clinical approach. CONCLUSIONS In the rapid diagnosis of PTB, the clinical judgment of specialists augmented the utility of the NAA test: (1) specialists selected patients with high-to-moderate pretest probabilities, (2) they commenced treatment promptly on a positive NAA test result, and (3) they were willing to start treatment in some patients on the basis of high clinical suspicion despite negative smear and negative NAA test results.
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Khoo SM, Lim TK. Prescribing and administration of nebulized bronchodilators: a prospective audit in a university hospital. Respirology 2003; 8:205-7. [PMID: 12753537 DOI: 10.1046/j.1440-1843.2003.00442.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Inaccurate and incomplete prescribing of nebulized bronchodilators can result in uncertainty and suboptimal treatment. A prospective study was carried out to assess the completeness of prescription and the quality of bronchodilator drug administration via nebulizers. METHODOLOGY A total of 121 consecutive inpatient nebulized bronchodilator prescriptions and treatments administered to 93 adult medical inpatients in a university hospital were studied prospectively. Five different aspects of the prescriptions were examined to assess their accuracy and completeness. The administration of each nebulizer treatment was studied using audit of medication charts and interview with ward nurses. RESULTS No prescription was correct and complete in all five aspects assessed. The most common mistake was failure to state the type and flow rate of driving gas (100%). This was followed by failure to prescribe recommended doses of bronchodilators (46%) and failure to give unambiguous instruction on frequency of treatment (39%). It was found that in only 21.5% of instances was the administration of nebulized bronchodilator drugs optimal. CONCLUSION This prospective audit has demonstrated major deficiencies in the prescribing and administration of nebulized bronchodilators and it has highlighted the need for a local protocol and continuing staff education. The alternative method of administering bronchodilator via metered dose inhaler with large volume spacer should be evaluated in the treatment of acute airflow obstruction in hospitalized patients.
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Lim TK, Zhu D, Gough A, Lee KH, Kumarasinghe G. What is the optimal approach for using a direct amplification test in the routine diagnosis of pulmonary tuberculosis? A preliminary assessment. Respirology 2002; 7:351-7. [PMID: 12421244 DOI: 10.1046/j.1440-1843.2002.00410.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aim of this study was to determine the most appropriate strategy for the rapid diagnosis of pulmonary tuberculosis (PTB) using a nucleic acid amplification (NAA) test. METHODOLOGY This was a prospective study of 128 adult patients in whom respiratory secretions were tested for Mycobacterium tuberculosis by the AMPLICOR assay. The basis for starting PTB treatment was noted for each patient. The optimal approach was determined by using Bayes' theorem to compare different combinations of pretest probability, smear results with the AMPLICOR test. RESULTS The incidence of PTB was 15.6%. In only one patient was treatment for PTB commenced because of a positive AMPLICOR result. The rest were managed according to the conventional approach which relied upon clinical judgment and direct smear. The optimal approach was to treat patients with high or intermediate pretest risk for PTB who returned positive AMPLICOR tests. The overall accuracies of the conventional approach, AMPLICOR test and optimal approach were 89.8, 95.3 and 96.1%, respectively. CONCLUSION This small study suggests that NAA testing be limited to patients with high or intermediate pretest risk of PTB. In this group, positive results demand treatment while the management of those with negative results still relies on clinical judgment.
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Yee YC, Gough A, Kumarasinghe G, Lim TK. The pattern of utilisation and accuracy of a commercial nucleic acid amplification test for the rapid diagnosis of Mycobacterium tuberculosis in routine clinical practice. Singapore Med J 2002; 43:415-20. [PMID: 12507028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
BACKGROUND Several nucleic acid amplification (NAA) tests are available for the rapid detection of Mycobacterium tuberculosis (MTB) in clinical specimens. AIMS To identify the pattern of utilisation and accuracy of the AMPLICOR test in routine clinical practice in an acute care setting. DESIGN A retrospective descriptive study. METHOD We studied 159 consecutive specimens in which the AMPLICOR (Roche; Branchburg, NJ) test was requested by attending doctors. The sensitivities and specificities of the AMPLICOR for detection of active tuberculosis (TB) were calculated in relation to types of specimens, smear and culture results. RESULTS The number of requests more than doubled from 1999 to 2000. Thirty-eight percent of the specimens were not from the respiratory tract. The majority of the specimens had requests for one or more additional test (mean 1.8). The rate of active TB was 18%. The sensitivities of the AMPLICOR on per specimen, per patient, per smear negative specimen and per smear negative patient basis were found to be 81%, 80%, 66.7% and 71.4% respectively. The specificities for these groups accordingly were 99%, 98.6%, 99% and 98.6% respectively. The sensitivity and specificity for respiratory specimens were 97.5% and 98.5%, while for non-respiratory specimens, they were 60% and 100%. In smear negative specimens, the sensitivity and specificity for respiratory specimens were 60% and 98.5%, while for non-respiratory specimens, they were 75% and 100%. The AMPLICOR assay was negative in all 21 specimens of pleural or spinal fluid. CONCLUSIONS There is a growing demand for NAA in the rapid diagnosis of TB with a high proportion of non-respiratory specimens. The number of additional diagnostic tests performed on each specimen should be limited. In routine clinical practice, the AMPLICOR assay is a useful confirmatory test for active pulmonary TB. The utility of the AMPLICOR assay for MTB detection in exudative fluid specimens needs further evaluation.
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Mahadevan M, Jin A, Manning P, Lim TK. Emergency department asthma: compliance with an evidence-based management algorithm. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2002; 31:419-24. [PMID: 12161875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Recent surveys in emergency medicine departments show inadequacies in many aspects of acute asthma management. OBJECTIVE The objective of this study was to evaluate the adherence to management algorithm for acute asthma in the emergency department which focused on evidence-based treatment steps rather than documentation and patient classification. METHODS A retrospective audit of consecutive adult patients with acute exacerbations of asthma in the emergency medicine department of a university hospital managed in the context of a clinical algorithm. RESULTS We collated information from 344 episodes of acute asthma (94% of total) over a 4-month period. The first-line treatment was nebulised bronchodilators in 97%, combination of salbutamol and ipratropium bromide in 93% and the combination in recommended dosages in 87%. Systemic corticosteroid treatment was administered to 82% of patients. A further course of systemic corticosteroid was prescribed at discharge for 94% of patients. Overall, 93% of patients received some form of systemic corticosteroid treatment. The admission rate was 35.2%, and was significantly higher in women and the elderly. Of those who were admitted, 46.2% received > or = 3 nebulised treatments and 69% received intravenous hydrocortisone. CONCLUSIONS In the management of acute asthma, we found excellent compliance with specific treatment steps based upon clinical evidence. However, adherence to second-line treatment was less satisfactory. Nevertheless, whenever second-line treatment was complied with, reasonable outcomes were achieved. It may be more appropriate to emphasise evidence-based treatment rather than extensive documentation.
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