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  • Professor, Department of Clinical Pharmacy, West Virginia University School of Pharmacy
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The use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be avoided in patients refractory ascites. Oral midodrine has been shown to improve clinical outcomes and survival in patients with refractory ascites; its use should be considered in this setting. Serial therapeutic paracenteses are a treatment option for patients with refractory ascite (Class I, Level C) 21. Post-paracentesis albumin infusion may not be necessary for a single paracentesis of less than 4 to 5 L. Referral for liver transplantation should be expedited in patients with refractory ascites, if the patient is otherwise a candidate for transplantion. Ascitic fuid infection is sufciently common (12% in an older series) at the time of admission of a patient with 18 cirrhosis and ascites to justify a diagnostic paracentesis. Empiric treatment of suspected infection without a sample for testing does not permit narrowing the spectrum of coverage compared to the situation when an organism is cultured that is susceptible to a narrowspectrum antibiotic. Dipstick testing of ascitic fuid and automated cell counts may improve early 31-33 detection of this infection, literally within 2-3 minutes. Older studies used urine dipsticks that were not calibrated 3 9 32 to 250 cells/mm [0. A newer dipstick 3 9 33 specifcally designed for ascitic fuid and calibrated to 250 cells/mm [0. The patients who meet the above criteria but have negative cultures have been labeled with a diagnosis of culture 126 3 negative neutrocytic ascites. The majority of patients with culturenegative neutrocytic ascites continue with this pattern of ascitic fuid analysis when serial 128 samples are obtained in rapid sequence before initiation of antibiotic therapy; 34. Delaying treatment until the ascitic fuid culture grows bacteria may result in the death of the patient from overwhelming infection. In some patients, infection is detected at the bacterascites stage before there is a neutrophil response, 3 9 129 i. Empiric antibiotic treatment (for presumed ascitic fuid infection) of patients with alcoholic hepatitis who have fever and/or peripheral leukocytosis can be discontinued after 48 hours if ascitic fuid, blood, and urine cultures demonstrate no bacterial growth. Cefotaxime, a third-generation cephalosporin, has been shown to be superior 131 to ampicillin plus tobramycin in a controlled trial. Dosing of cefotaxime 2 g intravenously every 8 hours has been shown to result in excellent 133 ascitic fuid levels (20-fold killing power after 1 dose). Risk factors for multiresistant infections include: nosocomial origin of infection, long-term norfoxacin prophylaxis, recent infection with 135 multiresistant bacteria, and recent use of lactam antibiotics. In order to minimize bacterial resistance, it is prudent to limit prophylactic antibiotics to patients who meet the inclusion criteria of randomized trials (see below), minimize duration of antibiotic treatment of infections, and narrow the spectrum of coverage, once susceptibility testing results are available. Intravenous ciprofoxacin followed by oral administration of this drug was found to be more cost-efective compared to intravenous ceftazidime in a 140 randomized trial in patients who had not received quinolone prophylaxis. Patients who have received quinolone prophylaxis may become infected with fora resistant to quinolones and should be treated with alternative agents. Improving control of a complication of advanced cirrhosis is commonly reported; however, 142 dramatically improving survival is seldom shown. Albumin has been shown to be superior to hydroxyethyl 144 starch in spontaneous bacterial peritonitis. Less than 5% of 145 infected ascites is due to a intra-abdominal surgically treatable source. Secondary peritonitis can be divided into two subsets: those with free perforation of a viscus. In contrast, the initial ascitic fuid analysis and the response to treatment can assist with this 35 important distinction. These criteria have been shown 35 to have 100% sensitivity but only 45% specifcity in detecting perforation in an older prospective study. A more recent study has confrmed 96% sensitivity of the above 3 criteria and/or polymicrobial culture; a computerized 145 tomographic scan was diagnostic in 85% of patients with secondary peritonitis.

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In select circumstances, employing a shared decision Antibiograms provide the clinician critical data making process with informed patients, initiation of a regarding choice of agents, particularly when selecting short treatment course of antibiotic therapy at the empiric antibiotics pending urine culture and sensitivity discretion of the patient (self-start) therapy may be results. Clinicians should omit surveillance urine women, and 2) patients undergoing elective urologic testing, including urine culture, in surgery. Prospective observational recommend the routine treatment of urease-producing studies have found no differences in rates of bacteriuria (including P. However, all analyses fluoroquinolones or nitrofurantoin with respect to risk of were based on small numbers of trials; no antibiotic resistance or other adverse events. There were no statistically significant not all harms were reported for all comparisons. In addition to the small number of trials available for each comparison within the systematic review also found no differences the network, other shortcomings of this analysis include between nitrofurantoin or fluoroquinolones versus failure to report direct and indirect estimates lactams in short or long-term symptomatic or 113 separately, the consistency between direct and indirect bacteriological cure. Data on risk of resistance relatively little to distinguish one agent from another. A recommended for empiric use in areas in which local network meta-analysis was performed with results 91 resistance rates exceed 20%. Generally, all effects on short or long-term bacteriological failure antibiotics have risks; as such, stewardship should be was not statistically significant. A three-day course of exercised to balance symptom resolution with reduction antibiotics was associated with decreased risk of in risk of recurrence. Overall, antibiotic prophylaxis reduced the number of the duration of preventive treatment ranged from 6 to clinical recurrences when compared to placebo in pre 12 months. The effect of the antibiotic prophylaxis prophylaxis ranged from 2 to 7 in trials that reported lasted during the active intake time period. The rate of possible serious pulmonary or use of fluoroquinolones, such as ciprofloxacin, for hepatic adverse events has been reported to be prophylactic antibiotic use is not recommended in 155 0. These There is little evidence on the benefits of rotating patients were more likely to have long-term exposure antibiotics used for prophylaxis. In a different to nitrofurantoin, highlighting the need for caution population of inpatient hospital treatment of infection, when prescribing long-term and avoiding nitrofurantoin informed switching strategies, 149, 150 have been used in patients with chronic lung disease. However, there is 158 Beers Criteria, with the strength of recommendation not enough evidence in the existing published literature as strong and a listed quality of evidence of low. The to reach reliable conclusions regarding the efficacy of 2015 Beers update has been modified to recommend cycling antibiotics as a means of controlling antibiotic avoidance of nitrofurantoin when creatinine clearance is resistance rates. Nitrofurantoin-induced lung injury can estimates were inconsistent, and occur in the acute, subacute or chronic setting, most nitrofurantoin was associated with increased risk of 165 commonly presenting with a dry cough and dyspnea. In a 1980 nitrofurantoin and other antibiotics in risk of 151 analysis of 921 reported cases by Holmberg et al. Other side effects monitoring is important to avoid the potential adverse included vaginal and oral candidiasis, skin rash, and events associated with nitrofurantoin. One of the trials compared disturbances), decreased oxygen carrying capacity a single dose of antibiotics for exposures to different. The other intermittent dosing trial gestational age, hyperbilirubinemia), interactions with compared a single dose of ciprofloxacin after sexual other drugs. In clinical practice, the In general, there is sparse reporting of antibiotic duration of prophylaxis can be variable, from three to resistances, with little data specifically on the impact of six months to one year, with periodic assessment and long-term antibiotic therapy on antibiotic resistance. Some women continue continuous or post There are data on the effects of antibiotic prescribing coital prophylaxis for years to maintain the benefit on antimicrobial resistance in individual patients.

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Complications were extraperitoneal insufflation, insufflation pressures 10 mm Hg indicating correct omental and bowel injuries, and failed laparoscopy. The various Veress needle safety tests or checks provide an appropriate intra-abdominal pressure remains contro very little useful information on the placement of the versial. Elevation of the anterior abdominal wall at the time of reduced to zero at 15 mm Hg, and the tip of the trocar Veress or primary trocar insertion is not routinely recom touched abdominal contents; when the same force was mended, as it does not avoid visceral or vessel injury. The combined results of three series involving 8997 Adequate pneumoperitoneum should be determined by laparoscopies using entry pressures of 25 to 30 mm Hg a pressure of 20 to 30 mm Hg and not by predetermined included reports of four (0. In the Veress needle method of entry, the abdominal ries, the bowel was adhered at the entry site of the anterior pressure may be increased immediately prior to insertion abdominal wall, and the vascular injury occurred because of of the first trocar. It has been demonstrated that the suggested benefits are prevention of gas embolism, of the use of transient high-pressure pneumoperitoneum preperitoneal insufflation, and possibly of visceral and causes minor hemodynamic alterations of no clinical signifi major vascular injury. The entry have not been shown to differ from the effect of is essentially a mini-laparotomy. A small incision is made Trendelenburg position with intra-abdominal pressure at 92, 95 transversely or longitudinally at the umbilicus. Sutures are placed on known periumbilical adhesions or history or presence of either side of the cannula in the fascia and attached to the umbilical hernia, or after three failed insufflation cannula or purse-stringed around the cannula to seal the attempts at the umbilicus. At the end of the procedure the fascial defect Garry reviewed six reports (n = 357 257) of closed laparos is closed and the skin is re-approximated. The open tech copy and six reports and one survey (n = 20 410) of open nique is favoured by general surgeons and considered by laparoscopy performed by gynaecologists. With the closed some to be indicated in patients with previous abdominal entry technique, the rates of bowel and major vessel injury surgery, especially those with longitudinal abdominal wall were 0. When the survey report (n = 8000) was excluded, the rate of bowel injury Several studies on the benefits and complications of the with the open technique was 0. Hasson advocated the open technique the randomised controlled trials comparing closed as the preferred method of access for laparoscopic (Veress plus trocar) versus open approach have inade surgery. However, the use of either technique, the visceral and vascular complication rates were techniques may have advantages in specific patient 0. In a published record of his own 29-year experience with laparoscopy in 5284 patients, A 2002 meta-analysis of English language studies from both Hasson reports only one bowel injury within the first 50 the gynaecological and general surgical literature addresses cases. Mortality rates after closed and open laparoscopy evidence as they are primarily mail-in surveys or chart were respectively 0. The findings of this meta-analysis showed that vas cular injuries are prevented almost entirely by the open the Swiss Association for Laparoscopic and technique (4. When all contrast to findings in general surgery publications by open laparoscopies were excluded from the analysis, the Sigman et al. In addition, they pointed A multicentre questionnaire survey of general surgeons out that gynaecologists may have more experience than (57% responding) reported a relatively high incidence of general surgeons with laparoscopic surgery. This may be influenced by patient selection bias, as open procedures may be more In clinical trials that compared closed and open entry tech likely to be chosen for patients who have had previous niques, the complication rates were 0. Another potential bias is that the num the closed and open techniques, respectively. The bowel and major vessel They found that bowel injuries were no less common with injury rates were 0. They concluded that open laparos injuries of the small bowel in four patients, two with delayed copy does not reduce the risk of major complications dur 104 recognition and death, and with retroperitoneal vessels in ing laparoscopic access. In the remaining 10 patients, there were four methods used by general surgeons and gynaecologists to instances of colon injuries, three of abdominal wall vessel establish access for laparoscopic surgery. They noted that laceration, and one each of liver, urinary bladder, or mesenteric vessel injury. The result was a clear trend and 13% to 50% of vascular injuries are undiagnosed at the towards a reduced risk of major complications in unselected time of surgery.

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The purpose of this book is to provide contemporary factual information on Insulin resistance. The articles in this issue provide a valuable overview of insulin resistance, by integrating the recent advances which have occurred in various seemingly disparate fields. Thus, I have relied on the expertise of several outstanding contributors who are recognized authorities in their respective areas. I hope that this book will serve as a valuable resource for all clinicians in the related fields and also for the students. Sarika Arora Lady Hardinge Medical College, India Section 1 Molecular and Genetic Basis of Insulin Resistance Chapter 1 Molecular Basis of Insulin Resistance and Its Relation to Metabolic Syndrome Sarika Arora Additional information is available at the end of the chapter dx. It is characterized by insulin resistance, visceral adiposity, dyslipidemia and a systemic pro-inflammatory and pro-coagulant state [2]. Insulin resistance is defined as reduced insulin action in metabolic and vascular target tissues, hence higher than normal concentration of insulin is required to maintain normoglycemia. On a cellular level, it indicates an inadequate strength of insulin signaling from the insulin receptor downstream to the final substrates of insulin action involved in multiple metabolic and mitogenic aspects of cellular function [3]. The development of insulin resistance leads to many of the metabolic abnormalities associated with this syndrome. Recent studies have contributed to a deeper understanding of the underlying molecular mechanisms of Insulin resistance. This review provides a detailed understanding of these basic pathophysiological mechanisms which may be critical for the development of novel therapeutic strategies to treat/ prevent metabolic syndrome. Signalling through Insulin receptor and its downstream Pathways Insulin action is initiated by an interaction of insulin with its cell surface receptor [8]. Insulin binds to the extracellular subunit of the insulin receptor and activates the tyrosine kinase in the subunit {figure 1). Once the tyrosine kinase of insulin receptor is activated, it promotes autophosphorylation of the subunit itself, where phosphorylation of three tyrosine residues (Tyr-1158, Tyr-1162, and Tyr-1163) is required for amplification of the kinase activity [9]. Plasma membrane phospholipids, cytoskeletal elements, and protein ligands mediate these interactions [16, 17]. Insulin signalling molecules involved in metabolic and mitogenic action have been demonstrated to play a role in cellular insulin resistance. This suggests that the impairment of insulin activity leading to insulin resistance is linked to insulin signalling defects. Mechanisms related to Insulin resistance Two separate, but likely, complementary mechanisms have recently emerged as a potential explanations for Insulin resistance. Second, a distinct mechanism involving increased expression of p85 has also been found to play an important role in the pathogenesis of insulin resistance. The most common amino acid change is a glycine to arginine substitution at codon 972 (G972R), which has an overall frequency of 6% in the general population [48], with a carrier prevalence of 9% among Caucasians [49]. This suggests that there may be an interaction between the mutant allele and obesity, such that, in the presence of obesity, the mutant variant may aggravate the obesity-associated insulin resistance [49]. In Caucasians, Finns, and Chinese, however, this variant has not shown an associated with type 2 diabetes [58, 59]. Although the polymorphism was associated with decreased insulin sensitivity and impaired glucose tolerance in women with polycystic ovary syndrome [60], it showed no association with insulin sensitivity in other studies [59, 61, 62]. However, using formal cell function tests, associations with insulin secretion were not reproduced in German, Finnish, and Swedish populations [59, 61, 62]. Molecular Basis of Insulin Resistance and Its Relation to Metabolic Syndrome 9 Phosphorylation of Ser318 is not restricted to insulin stimulation. Elevated plasma levels of leptin, an adipokine produced by adipocytes [84], also stimulates the phosphorylation of Ser318. This report validates previous in vitro and in vivo studies in animal models and suggests that the same strategy could be employed to identify phosphorylated Ser/Thr sites under conditions of insulin resistance, obesity, or type 2 diabetes. Impaired hepatic glycogen storage and glycogen synthase activity is a common finding in insulin resistance [89] and polymorphisms in the glycogen synthase gene have been described in insulin resistant patients. The most frequent mutations are the so-called XbaI mutations and Met416Val within intron 14 and exon 10, respectively.

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It may be related to the urinary tract, the genital tract, the bowel, nervous system or muscular system. It may be due, for example, to bacterial, viral or fungal infections, infestations, stones, benign or malignant tumours, endometriosis, inflammatory systemic autoimmune disease, drugs or chemicals including in recent years ketamine abuse. Table 1 on page 20 provides a summary of many possible causes of these symptoms (so-called confusable diseases). However, if a thorough investigation has revealed none of these disorders, there is another possibility. While the symptoms may resemble a urinary tract infection (cystitis), tests show no infection in the urine and reveal no other disorder that could account for the symptoms. Current research into subtyping (or phenotyping) may lead to the identification of more subtypes in both of these categories. International Painful Bladder Foundation 2019 6 the pain or hypersensitivity may be experienced as discomfort, tenderness, irritation, burning or other unpleasant sensation in the bladder, or in the form of stabbing pain in or around the bladder, even in the vagina, or may simply be a feeling of pressure on or in the bladder or a feeling of fullness even when there is only a very little urine in the bladder. In many patients, the pain is relieved temporarily by urination, while some patients may also feel pain or burning following urination. It may also be felt throughout the pelvic floor, including the lower bowel system and rectum. Other patients may have frequency with/without urgency and without a sensation of true pain. What they may experience, however, is a feeling of heaviness, fullness, discomfort or pressure or simply an irritated sensation in the bladder. Urinary frequency means that a person needs to urinate more frequently than normal during the daytime and at night. However, this will also partly depend on how much a patient drinks, on the climate where the patient lives, how much the person perspires and on medication the patient may be taking which could have a diuretic effect. Some patients find that having to postpone urination leads to retention or difficulty in getting the flow started. However, prevalence figures vary enormously from study to study and country to country and depend on what criteria and definitions have been used for diagnosis and what diagnostic methods have been used to reach the diagnosis. Furthermore, many prevalence figures have tended to bundle all patients with a painful, hypersensitive bladder together, without making any distinction between lesion/non-lesion types. However, while this Hunner type interstitial cystitis used to be considered rare, it is now believed that it may be more common than originally thought but simply not getting diagnosed. Many researchers now believe that the classic type with Hunner lesions and the non-lesion type may be two different diseases. While some patients may have an inflammatory type of bladder condition, others may not and here too there may be further subtypes or phenotypes. The symptoms may begin for no apparent reason, or sometimes following surgery, for example in the case of women following a hysterectomy or other gynaecological or pelvic operation, after childbirth or following a bacterial infection of the bladder or repeated infections. Onset may be very slow, building up over many years or it may be sudden and severe. Some patients recall having bladder problems in childhood or adolescence, needing to go to the toilet more frequently than others, long before they developed pain. This leads many patients and their doctors to think that it may be an infection (bacterial cystitis). If the patient fails to respond to antibiotic treatment, it is important for a urine culture to be carried out (not just dipsticks) in order to be absolutely sure that bacterial infection can be excluded. In some patients, the symptoms may gradually worsen, but this greatly varies from patient to patient and is not necessarily International Painful Bladder Foundation 2019 8 the case.

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Another type of powder, called magnetic or magna powder, Other adhesive lifting media are hinge lifters, where the allows for application with a magnetized rod that has no adhesive square is attached to the backing card by a hinge; bristles. This type of powder can be light, dark, or fuo opaque adhesive gel lifters, typically black or white; and rescent and utilizes the ferromagnetic properties of iron silicon-type materials that are spread onto the surface powder mixed with pigment powders. The magnetized ap and allowed to harden to a fexible rubbery medium plicator (magna brush) is dipped into the powder, picking up before lifting. If the impression will be photographed in situ, the impor tance of powder color increases. Documenting powdered It is important to note that the magnetic powder ball impressions this way requires combining proper selec formed with a magna brush is much softer than conven tion of powder and photographic lighting that will produce tional flament brushes and typically causes less damage ample contrast against the substrate. Mag netic powders are usually less effective on ferromagnetic Another type of powder that produces excellent results substrates such as steel or nickel and are therefore not rec on a wide variety of surfaces is fuorescent powder. The magnetic attraction rescent powder relies on the principle of luminescence may cause contact between the applicator and substrate, to provide contrast between fngerprint and background. In addition, magne Fluorescent powders are typically created by adding a tized particles from the powder will cling to the substrate laser dye in solution to a binder and allowing the mixture and resist removal. The most common and simplest method is Fluorescent powdering is highly sensitive when used with lifting. To lift a print, good-quality transparent tape is placed a good forensic light source and the appropriate barrier onto the surface bearing a powdered impression. In theory, luminescent fngerprint powder should be tape size for fngerprint lifting is 1. With the advent of chromatography, the reac because fuorescence caused by lifting media will interfere tion became even more useful for the location of amino with the quality of the impression. Despite Crime scene examiners are being warned to be aware of these warnings, which clearly indicated the ability of ninhy this possibility. Ruhemann observed that detection on paper and other porous substrates (Champod the new compound reacted with skin and amino acids et al. As early as 1913, the reaction with amino Some fngerprints are created by the deposition of sweat acids was an important diagnostic test for the presence from the fngers when they come into contact with a sur of protein and amine compounds in biological samples face. O O Ninhydrin (2, 2-dihydroxy-1, 3-indanedione) 1, 2, 3-indanedione which comprise 98% of the volume of a fngerprint (Pounds for fngerprint development (Champod et al. Subsequent studies indicated that the with paper, these amino acids impregnate the surface of purple color resulted from the reaction between ninhydrin the paper, where they are retained by their high affnity for and amino acids and described the product of this reaction cellulose (Champod et al.

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Any questions regarding the necessity for additional lab 7 8 values should be clarified with the chief surgical resident and communicated to the nurse. The trauma attending on service not the on-call attending physician should be listed as the admitting physician. Any missing trauma admit forms are the responsibility of the chief surgical resident on-call that day. Any trauma admission form submitted incomplete will be returned to the chief resident for completion within 24 hours. Daily Census A daily census will be the responsibility of the off-going chief resident and his/her team. All patients admitted to or consulted by the service should be represented on the census. We realize there are emergent situations that necessitate immediate performance of procedures that would preclude prior attending physician notification. Procedure notes should be completed for all procedures regardless of whether the attending is present or absent. Procedures such as Intubation, bronchoscopy, Groshong catheter removal, suture of lacerations, etc. These 8 9 procedure notes are used to provide necessary and complete documentation in the medical record for procedures performed. There has been some confusion about procedures performed in the Emergency Department after hours and on weekends. The supervising attending physician for emergency department patients is the attending surgery physician listed on the call schedule not the blue surgery attending on the service. There are occasions when the blue service attending is present after hours and on weekends and should be listed as the supervising physician. A brief written note should appear in the progress notes that documents the procedure and indicates that a more detailed note will follow. For all procedures the following information must be provided: Name: Diagnosis: Reg Number: Indication: Date of Procedure: Resident Surgeon: Location: Attending Surgeon: Service: (performing the procedure) Preparation: Anesthetic: Progress Notes and Medical Chart Documentation Please remember that the medical chart is a legal document. Daily progress, as well as any and all acute changes in patient condition should be documented in the chart completely, accurately and legibly with the appropriate date and time. After 6:00 am and before 5:00 pm, it is permissible to triage appropriately to other general surgery services (Green and Gold) but only after appropriate evaluation and reasonable diagnostic possibilities have been established. The triage or transfer of service should be arranged between the chief surgical residents and/or between service attendings not between junior house officers. The only exception to these rules is elective general surgery consults directed specifically to one of the Blue (Trauma/Emergency) Surgery attendings. Timely consultant notification and patient evaluation are necessary to minimize emergency department length of stay and to insure high quality patient care. We expect the Trauma/Emergency Surgery service residents to adhere to these guidelines. Consultants should be notified promptly following completion of the secondary survey (<20 minutes after patient arrival) or sooner if their services are required (acute neurosurgical, face team, cardiothoracic, or orthopedic intervention). Consultants should be present for patient evaluation within 20 minutes of notification. Fifth floor west has been designated as the trauma/emergency surgery service ward. Patients with multi-system trauma and significant or predominant orthopedic injuries should be admitted to 5 South. The admitting office is aware of the trauma service ward but may need prompting or direction for admission to 5 West and 5 South. Referring Physician Calls Receiving referring physician calls is a necessary part of resident education. Any other resident or intern receiving such a call should immediately forward the call to his/her chief resident. During the initial discussion with the referring physician, the chief can and should make appropriate recommendations and suggestions regarding patient care prior to transport in order to ensure optimal transfer. Floor Call Primary floor calls are the responsibility of the Blue Surgery Intern on call. Questions or problems regarding floor patients should be directed to the chief surgical resident on call.

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I would like to express my heartfelt gratitude to everyone who was involved in the development of these guidelines and especially to the working group members for their enthusiasm, relentless effort and immense contribution. Bethesda, Maryland: Us Department Of Health And Human Services, Public Health Service, National Institute Of Health. Members responsible for each section were tasked to ensure that the relevant literature was adequately searched, retrieved, critically appraised and accurately presented. The full text of reference articles quoted in these guidelines was carefully studied. In addition, the reference lists of relevant articles retrieved were searched to identify other studies. Each section leader presented his/her section of the proposed guidelines at several meetings where all members of the working group met and participated in the discussion. The fnal draft of these guidelines inclusive of recommendations was the result of agreement by the majority, if not all, members of the working group at such meetings as well as through e-mail discussions in between the meetings. Throughout the development of these guidelines, a total of six meetings were held from 10 January 2009. In situations where the evidence was insuffcient or lacking, the recommendations made were by consensus of the working group. The draft guidelines were also posted on the Ministry of Health Malaysia website for comments and feedback. These guidelines were presented to the Technical Advisory Committee for Clinical Practice Guidelines and the Health Technology Assessment and Clinical Practice Guidelines Council, Ministry of Health Malaysia for review and approval. Mohd Idzwan Zakaria Senior Consultant Chest Physician Emergency Medicine Physician Hospital Pulau Pinang Pusat Perubatan Universiti Malaya Pulau Pinang Kuala Lumpur Datin Dr. Pang Yong Kek Senior Consultant Chest Physician Consultant Chest Physician Institut Perubatan Respiratori Pusat Perubatan Universiti Malaya Hospital Kuala Lumpur Kuala Lumpur Kuala Lumpur Dr. Richard Loh Li Cher Chest Physician Consultant Chest Physician Hospital Universiti Sains Malaysia Kolej Perubatan Pulau Pinang Kubang Kerian Pulau Pinang Kelantan Assoc. Rohaya Abdullah Consultant Chest Physician Family Medicine Specialist Pusat Perubatan Universiti Kebangsaan Malaysia Klinik Kesihatan Masai Kuala Lumpur Johor Bahru Dr. Yap Boon Hung Consultant Primary Care Physician Consultant Chest Physician Pusat Perubatan Universiti Malaya Hospital Tung Shin Kuala Lumpur Kuala Lumpur Dr. Zainudin Md Zin Senior Consultant Chest Physician Senior Consultant Chest Physician Leong Oon Keong Chest & Medical Clinic Sdn. Ashoka Menon Senior Consultant Chest Physician Pusat Perubatan Sime Darby Subang Jaya Associate Professor Ayiesah Hj Ramli Physiotherapy Programme Coordinator Faculty of Allied Health Sciences Universiti Kebangsaan Malaysia Kuala Lumpur Ms P. Devashanti Pharmacist Pusat Perubatan Universiti Malaya Kuala Lumpur Associate Professor Dr Fanny Ko Wai-San Department of Medicine and Therapeutics the Chinese University of Hong Kong Hong Kong Dr. Hooi Lai Ngoh Senior Consultant Chest Physician Public Specialist Centre Georgetown Dr. Jamalul Azizi Abdul Rahman Head of Department & Consultant Respiratory Physician Department of Respiratory Medicine Hospital Queen Elizabeth Kota Kinabalu Dr. Kuppusamy Iyawoo Senior Consultant Chest Physician Hospital Assunta Petaling Jaya Puan Nurhayati Mohd. Nur Clinical Nurse Specialist in Respiratory Medicine Nursing Offcer Pusat Perubatan Universiti Malaya Kuala Lumpur Dr. Wong Wing Keen Senior Consultant Chest Physician Pusat Perubatan Sunway Petaling Jaya Dr. Airfow limitation, associated with an abnormal infammatory reaction of the lung to noxious particles or gases, the most common of which worldwide is cigarette smoke, is usually progressive, especially if exposure to the noxious agents persists. Airfow limitation is best measured by spirometry, the most widely available and reproducible test of lung function. Spirometry should be performed after an adequate dose of an inhaled bronchodilator.