Asthma insights and reality in the Gulf and the near East

BACKGROUND

Data on the burden of asthma and the quality of asthma control in the Gulf and Near East (GNE) are scarce.

OBJECTIVE

To determine how closely asthma management guidelines are being followed in the GNE.

METHODS

The Asthma Insights and Reality in the GNE (AIRGNE) survey is based on information from 1000 patients with asthma in five countries: Jordan, Kuwait, Lebanon, Oman and the United Arab Emirates (UAE).

RESULTS

Daytime asthma symptoms were reported by 68% of respondents, and 51% reported being woken up by asthma in the preceding 4 weeks. Use of health services in the last 12 months was high, with 23% having been hospitalised and 52% having attended the emergency department. Absence from school and work in the past year was reported by 52% of children and 30% of adults. The highest school absence was observed in Jordan and Lebanon (both 69%), and Jordan had the highest rate of absence from work among adults (46%). The use of peak expiratory flow was very low, and only 17% owned a meter. Overall, 66% of participants had never undergone a lung function test.

CONCLUSION

Current levels of asthma control in the GNE fall far short of the goals specified in guidelines for asthma management.

Primary mediastinal liposarcoma: a case report and review of the literature

A case of mediastinal liposarcoma (LPS) in a 49-year-old female is described. Primary LPS of the mediastinum are very rare tumors. They occur mainly in adults but may be encountered in children. They are characterized by their large size and their variable histologic subtypes, which correlate with the clinical behavior and the prognosis. The radiologic features are nonspecific but are suggestive of the diagnosis. A tissue biopsy is needed for the final diagnosis. The treatment of choice is surgical with wide margin resection. Chemotherapy and radiotherapy are ineffective modalities, used in unresectable or incompletely resected tumors. The prognosis depends on the histologic subtypes and completeness of surgical excision.

Transfusion associated graft versus host disease in immunocompetent patients. Report of two cases

Transfusion graft versus host disease (TGVHD) in immunocompetent patients is a recently recognized disease, reported mainly after open heart surgery, and almost always fatal. We report two cases of TGVHD in immunocompetent patients after open-heart surgery. The disease is characterized by the occurrence of fever, skin rash, liver failure and pancytopenia. Preventive measures include exclusion of first- and second-degree relatives as blood donors, and/or irradiation of blood to be transfused.

Allergic bronchopulmonary aspergillosis and sensitization to Aspergillus fumigatus in chronic bronchiectasis in adults

Fifty adult subjects for whom a diagnosis of idiopathic bronchiectasis (excluding those secondary to tuberculosis or hypogammaglobulinaemia) had been confirmed previously were investigated by: questionnaire; blood eosinophil count; sputum culture for Aspergillus fumigatus and eosinophil count; chest radiography; skin-prick tests with several aeroallergens and four preparations of A. fumigatus, including a reference extract; measurement of specific IgE antibodies; precipitin testing and self-crossed immunoelectrophoresis with A. fumigatus. Five subjects were possible cases of allergic bronchopulmonary aspergillosis in whom the condition had been previously misdiagnosed or in whom sensitization to A. fumigatus had occurred after the onset of bronchiectasis. These five subjects had positive immediate skin reactions to A. fumigatus and a history of recurrent pneumonias. Four had a previous history of asthma and the others showed increased bronchial responsiveness to inhaled methacholine. At the time of the survey, A. fumigatus grew in the sputum of one out of five subjects. These subjects had increased levels of specific IgE. Two had precipitins by double diffusion and three subjects were positive on self-crossed immunoelectrophoresis. It is concluded that allergic bronchopulmonary aspergillosis or evidence of sensitization to A. fumigatus can be identified in a significant proportion of adult subjects with so-called idiopathic bronchiectasis.

Monitoring of peak expiratory flow rates in subjects with mild airway hyperexcitability

Twenty-seven subjects with mild symptoms of bronchial hyperexcitability (cough, dyspnea, wheezing) and low to moderate degree of airway response to histamine monitored their peak expiratory flow rates (PEFR) for a mean +/- SD of 14.4 +/- 4.0 days. This assessment was performed without the use of any medication in 15 subjects, and before and after inhalation of salbutamol in 12 others. 100% and 52% of individuals, respectively, showed baseline FEV1 and maximum mid-expiratory flow rates greater than 80% of predicted. The improvement in FEV1 after salbutamol was less than 20% in every subject and from 10 to 20% in 15%. The mean daily percentage changes in PEFR were greater than the ones observed in normal individuals in only 21% and 50% of the subjects on no medication and on salbutamol, respectively. Diurnal changes in PEFR were significantly negatively correlated with the response to histamine (r = -0.51; p less than 0.01) and baseline FEV1 (r = -0.49; p less than 0.02). We conclude that there are minor fluctuations of PEFR in subjects with mild symptoms and low degree of airway excitability.

Pulmonary function tests and airway responsiveness to methacholine in chronic bronchiectasis of the adult

Fifty adults with chronic bronchiectasis (mean duration since diagnosis: 25 +/- 16.4 years), excluding those cases secondary to tuberculosis or hypogammaglobulinemia, were investigated by a questionnaire, a chest radiograph and lung function tests. Of these, 29 with an FEV1 greater than 1.5 1 underwent methacholine inhalation tests. Fourty-three subjects and three subjects respectively showed an obstructive or a mixed obstructive and restrictive defect, only four having normal lung function tests. Sixty-nine percent of subjects tested had a provocative concentration of methacholine causing a 20% fall in FEV1 (PC20) less than 16 mg X ml-1. Subjects with daily sputum production had lower values of FEV1 and FEV1/forced vital capacity (FVC) compared to subjects with less than daily sputum. Subjects with clinical features of bronchial hyperexcitability had significantly lower baseline FEV1, vital capacity, and maximal mid-expiratory flow rate (FEF25-75). Subjects with lower PC20 values had significantly lower baseline FEV1, FEV1/FVC and FEF25-75. Finally, subjects with the greatest extent of radiological abnormalities had lower baseline FEV1, FEV1/FVC and diffusing capacity, and a higher residual volume. We conclude that chronic bronchiectasis is associated with significant changes in lung function tests and increased responsiveness to methacholine in the majority of affected individuals.

Nonallergic bronchial hyperexcitability in chronic bronchitis

The aim of this study was to assess responsiveness to inhaled histamine and methacholine using PC20, the concentration causing a 20% fall in forced expiratory volume in one second (FEV1) in 28 subjects with chronic bronchitis excluding asthma. Eighteen subjects had airway hyperexcitability, as demonstrated by a PC20 less than 16 mg/ml. The response to histamine and methacholine was not significantly different and the correlation coefficient was 0.75. Baseline airway caliber was related to the level of hyperexcitability, as 14 of 14 subjects with a FEV1 to forced vital capacity ratio less than 95% pred and/or a forced expiratory flow during the middle half of the FVC less than 80% pred, and only 4 of 10 subjects with normal spirometry, had a PC20 less than 16 mg/ml (x2 = 15.6, p less than 0.001). There was no correlation between blood or sputum eosinophilia, total IgE levels, or atopy and the level of airway hyperexcitability. Spontaneous daily variations of peak expiratory flow rates were significantly (t = 2.43, p less than 0.05) more pronounced in subjects with PC20 less than 16 mg/ml. We conclude that airway hyperexcitability assessed with PC20 is often present in chronic bronchitis and more often so in the presence of airway obstruction.