Clinical standards for the diagnosis and management of asthma in low- and middle-income countries

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

ESR and photoluminescence properties of Cu doped ZnS nanoparticles

Nanoparticles of Zn1-xCuxS with Cu concentrations of x=0.0, 0.1, 0.2, 0.3 and 0.4 were prepared by a co-precipitation reaction method from homogeneous solutions of zinc and copper salts. Both the ZnS and ZnS:Cu nanoparticles excited at about 370 nm exhibits a broad green emission band peaking around 491 nm, which confirms the characteristic feature of Zn2+ as well as Cu2+ ions as luminescent centers in the lattice. The TEM micrographs showed spherical morphology for ZnS nanocrystals and the average size of the particles was estimated to be around 8.5 nm. At liquid nitrogen temperature, ESR signal characteristic of Cu2+ ions was observed in samples of all concentrations. ESR spectra analysis also indicated that Cu2+ ions enter the host lattice by replacing Zn2+ ions with distorted tetrahedral site symmetry.

Nanostructured Cd(1-x)Mn(x)S films for spintronics and optoelectronic device applications: synthesis and characterization

Nanostructured Cd(1-x )Mn(x)S (x = 0.3 and 0.4) films were prepared on glass substrates by thermal evaporation. All the films were deposited at 373 K and annealed at 473 K in high vacuum of 2 x 10(-6) mbar. The nanostructure films were characterized for composition, structure, morphology, optical and magnetic properties. All the films exhibited wurtzite structure of the host CdS material. AFM studies showed that all the films were in nanocrystalline form with the grain size varying in the range of 25-43 nm. The magnetic susceptibility increased sharply with Mn content 'x'.

Optical and electrical studies of vapour phase grown Cd1-xCoxTe crystals

The optical properties of vapour phase grown crystals of diluted magnetic semiconductor (DMS) Cd1-xCoxTe were investigated for x=0.001, 0.003, 0.005, 0.007 and 0.009. The reflectivity spectra exhibited a regular shift in the fundamental absorption edge (E0) with composition x. The reflectivity spectra for the present samples of Cd1-xCoxTe of all compositions exhibit broad bands at 5300 and 11,100cm(-1) due to the transitions of 4A2-->4T1 (F) and 4A2-->4T1 (P), respectively. Temperature dependence of resistivity revealed semiconducting behaviour of the samples. Hot probe test revealed that all the samples exhibited p-type conductivity.

EPR and susceptibility studies on (ZnS)1-x(MnTe)x powders

(ZnS)1-x(MnTe)x luminescent powder samples with x=0.02, 0.05, 0.10, 0.15, 0.20 and 0.25 were prepared by solid-state reaction method. EPR spectra were recorded at room temperature (300K) in the frequency range 8.8-9.6GHz for samples of all compositions. The line width (DeltaH) and the number of spins increased with MnTe concentration. Room temperature dc magnetic susceptibility measurements were carried out using vibrating sample magnetometer. Susceptibility of the samples increased with MnTe content.

ac susceptibility and ESR studies on vapour phase grown Cd(1-x)Mn(x)Te crystals

Single crystals of Cd(1-x)Mn(x)Te for x = 0.1, 0.2, 0.3, 0.4 and 0.5 were grown by a modified vapour phase growth technique. ac magnetic susceptibility studies were carried out in the temperature range 14-300 K. Both the real and the imaginary parts of susceptibility indicated the formation of spin-glass phase at low temperatures. ESR spectra were recorded at room temperature (300 K) at 9.4 GHz for samples of all compositions. The line width (DeltaH) increased with Mn content.

EPR and susceptibility studies of Zn1-xMnxTe crystals at room temperature

Single crystals of Zn1-xMnxTe for x = 0.1, 0.25, 0.45, 0.5 and 0.6 were prepared using vertical Bridgman technique. EPR (electron paramagnetic resonance) spectra were recorded at room temperature (303 K) between 0 and 6 kG magnetic field and range of frequency 8.8-9.6 GHz. As the concentration of Mn increases the line width (DeltaH) and the number of spins (Ns) were increased. Susceptibility studies were carried out at room temperature in the range of dc magnetic field 0-10 kG using vibrating sample magnetometer (VSM). Non-linear variation in susceptibility as a function of concentration (x) was observed and was explained on the basis of sp-d and d-d exchange interactions between Mn2+ ions and ZnTe lattice ions. Both EPR and susceptibility studies confirm the paramagnetic state of Zn1-xMnxTe system at RT.

A rapid and sensitive extractive spectrophotometric determination of copper(II) in pharmaceutical and environmental samples using benzildithiosemicarbazone

Benzildithiosemicarbazone (BDTSC) is proposed as a sensitive and selective analytical reagent for the extractive spectrophotometric determination of copper(II). BDTSC reacts with copper(II) in the pH range 1.0-7.0 to form a yellowish complex. Beer's law is obeyed in the concentration range 0.5-0.4 microg cm(-3). The yellowish Cu(II)-BDTSC complex in chloroform shows a maximum absorbance at 380 nm, with molar absorptivity and Sandell's sensitivity values of 1.63 x 10(4) dm3 mol(-1) cm(-1) and 0.00389 microg cm(-2), respectively. A repetition of the method is checked by finding the relative standard deviation (RSD) (n = 10), which is 0.6%. The composition of the Cu(II)-BDTSC complex is established as 1:1 by slope analysis, molar ratio and Asmus' methods. An excellent linearity with a correlation coefficient value of 0.98 is obtained for the Cu(II)-BDTSC complex. The instability constant of the complex calculated from Edmond and Birnbaum's method is 7.70 x 10(-4) and that of Asmus' method is 7.66 x 10(-4), at room temperature. The method is successfully employed for the determination copper(II) in pharmaceutical and environmental samples. The reliability of the method is assured by analyzing the standard alloys (BCS 5g, 10g, 19e, 78, 32a, 207 and 179) and by inter-comparison of experimental values, using an atomic absorption spectrometer.

Neck mestastasis from unknown origin-results of planned primary surgery and post-operative radiation therapy

Ninety-two patients with metastasis of unknown origin were studied between 1986 and 1997 at Kidwai Memorial Institute of Oncology, India. Treatment included planned primary radical neck dissection followed by radiotherapy. Sixty-seven patients completed our multimodal therapy. Thirty-eight of these patients had a median follow-up pf 35.7 months. Nine patients had a median follow-up of 8.3 months. Twenty patients were lost in follow-up after completing the above protocol. Twenty-five patients did not comply with prescribed therapy. Of the followed up patients 78.9% were disease free. The failure rate was 21%, which comprised of regional failure in 16% and liver metastasis in 5%. Primary manifested at base of tongue in 2 patients. In a third world cancer center like ours, advanced neck disease and unreliable follow-up mandate multimodal therapy to be instituted at the first instance. Manifest primaries should be treated on individual basis.

Psychological well-being among cancer patients receiving radiotherapy--a prospective study

The impact of cancer on the psychological well-being of newly diagnosed cancer patients before and during the course of radiotherapy was assessed in 70 consecutive cancer patients. Most of the patients were over 40 years of age, women, illiterate and from a lower socioeconomic group. During the course of treatment there was a decrease in the well-being scores on some dimensions such as perceived family and primary group support. Improvements were seen in the dimensions of positive feelings, coping, social support other than the family and spiritual well-being. There were no changes in the dimensions of negative feelings and perceived ill-health. The results give a profile on well-being and the changes observed during radiotherapy.

Hepatocellular carcinoma metastatic to bones (Case report with review of literature)

A seventy year old man presented with bone pains. Investigation revealed a metastatic bone lesion in the humerus. The primary was found in the liver. The patient achieved good palliation with chemotherapy and radiotherapy and survived for one year.

Interjugular neck dissection and post-operative irradiation for neck control in advanced glottic cancers--are we justified?

At the Kidwai Memorial Institute of Oncology, advanced laryngeal cancers are subjected routinely to primary surgery and/or post-operative radiotherapy (RT). The surgery consists of wide field laryngectomy which entails total laryngectomy, ipsilateral/bilateral thyroid lobectomy, bilateral paratracheal clearance, and bilateral clearance of levels 2, 3 and 4 lymphatics. Post-operative RT is indicated in event of the following histopathological (HPE) situations to consolidate local-regional control: (1) T4 primary; (2) significant subglottic extension; and (3) jugular/paratracheal metastatic deposits. This prospective study highlights the therapeutic efficacy of this protocol at our centre in 45 consecutive T4/T3 glottic cancers and specifically evaluates the role of interjugular dissection and/or post-operative RT in prevention of regional recurrence. Fifty-two per cent of primary lesions needed a post-surgical upstaging as against 14 per cent of the neck lesions. Accordingly 91 per cent of the cases (41/45) qualified for post-operative RT and 82 per cent (37/41) complied with the prescribed schedule. Recurrent disease in the lateral neck was noted in 2/37 who received the prescribed schedule and 1/4 non-compliant cases; while a recurrent central neck disease was noted in 1/37 and 1/4 of these cases respectively. All cases were followed-up for a period of two years and 66 per cent of the evaluable cases for a period of five years. This study confirms conclusively that our treatment schedule yields extremely gratifying two-year local-regional control rates of 89 per cent which translates into a two and five-year actuarial survival rate of 92 and 70 per cent respectively.

Sero-prevalence of herpes simplex virus type-2 among cancer cervix patients

Serum samples were collected from 140 cancer cervix patients aged between 25-60 years and also from 20 age matched, married, healthy women to serve as controls. These sera were tested for HSV-2 antibodies by ELISA test and HBsAg by RPHA test. HSV-2 antibodies were detected in 92 (65-71%) and HBsAg in 25 (17.8%) cancer cervix patients. Sera from control group were negative for HSV-2 antibodies and HBsAg.

Neck metastasis from an occult primary--the Kidwai experience

This study highlights our treatment policy in 26 cases of epidermoid metastatic carcinoma in the neck from a primary deemed occult after exhaustive examination of the Upper Aero-digestive Tract (UADT). Planned Radical Neck Dissection (RND) and post-operative radiotherapy (RT) has been the favoured approach in all neck nodes deemed resectable and a loco-regional control rate of 64% was obtaining using this combined modality approach. Pre-operative RT was utilised in three cases with nodal disease of borderline resectability and loco-regional control was achieved in one case. Three cases of massive neck metastasis initially deemed unrectable became amenable to surgical salvage after Radical RT with concurrently administered chemotherapy. Only one of these remained disease free. Overall loco-regional control rate of 55 per cent could be achieved in 20 evaluable patients followed up for two years--three years (mean 30.5 months). Regional failures were noted in 25 per cent of patients while distant spread occurred in 15 per cent, thus accounting for an overall failure rate of 40 per cent. Manifest primaries were documented in 20 per cent, half of which could be salvaged and successfully controlled.

Mandibular metastasis in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) presenting initially as a bony metastasis is rare. Involvement of maxillofacial bones is even more rare and only 20 cases have been reported. A case of a 65-year-old male patient presenting with metastasis to the mandible from a primary HCC is described.

Girls with muscular dystrophy

Clinical and genetic studies were made on progressive muscular dystrophy in eight young girls. No chromosomal abnormality was observed in these patients and their mothers. The pedigrees of six cases suggested an autosomal recessive inheritance and clinical features were identical with those of Duchenne muscular dystrophy. Two other cases were compatible with childhood muscular dystrophy with autosomal recessive inheritance.

Juvenile oral angiofibroma in a female

A case of oral angiofibroma in a 14-year-old girl is presented. Unlike in earlier reports, the patient was confirmed as female by gynecological examination and other specific examinations. The possibility of the origin of the angiofibroma from the Meckel's cartilage is postulated. Any exuberant, sessile growth with a tendency toward spontaneous bleeding should be viewed with suspicion in terms of angiofibroma. Lesions such as pyogenic granulomas, hemangiomas, myxomas, and fibromyxomas should be kept in mind while making a diagnosis of angiofibroma. A biopsy examination as a routine office procedure should not be done on benign-looking masses with tendencies to bleeding.