Caspian Journal of Internal Medicine
Volume:10 Issue: 1, Winter 2019

Efficiency of non-invasive positive pressure ventilation in the treatment of respiratory failure has been shown in many published studies. In this review article, we introduced new modalities of non-invasive ventilation (NIV), clinical settings in which NIV can be used and a practical summary of the latest official guidelines published by the European Respiratory Clinical Practice. Clinical trials and review articles in four databases up to 25 February 2018 about new modalities of non-invasive positive pressure ventilation were reviewed. Commonly used modalities for treatment of respiratory failure include: CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airway pressure) or NIPSV (noninvasive pressure support ventilation). The limitations of the BiPAP method are the trigger and cycle asynchrony, inadequate volume delivery and increased respiratory rate. Newer methods, such as adaptive servo-ventilation, have been developed to treat central and complex sleep apnea and the NAVA (neutrally adjusted ventilatory assist) to improve the trigger and cycle asynchrony.
In the proportional assist ventilation, unlike the pressure support ventilation, with increased patient effort (flow) the tidal volume increases and it prevents the increase in the respiratory rate and respiratory distress. High-flow nasal cannula is a non-invasive technique that does not provide respiratory support, but provides a mixture of oxygen to the patient. The use of non-invasive pursed-lip breathing ventilation in chronic obstructive pulmonary disease (COPD) patients reduces dyspnea (decreases respiratory rate) and increases blood oxygen saturation. New modalities of NIV improve patient comfort and patient–ventilator interactions, and are recommended in patients with respiratory failure.

Lymphangioleiomyomatosis (LAM) is a progressive lungs disease that affects women at reproductive years. Sirolimus inhibits mammalian target of rapamycin (mTOR) and its administration in past studies was hopeful in treatment of patients with LAM. The aim of this study was to evaluate sirolimus therapy on lung function in LAM patients. We conducted a trial to evaluate the effect of sirolimus on six patients with LAM who had severe or very severe obstructive lung disease, and one-year follow up. Maintenance level of Sirolimus was 10-15 ng/ml. Serial visits (including physical examination, evaluation of signs and symptoms of disease and adverse events due to treatment), spirometry, 6MWT done at baseline 3, 6, 9 and 12 months after. Spirometric parameters walk distance and O2 saturationbefore and after exercise at first and the end of treatment were measured. Four patients had TSC-LAM while the other 2 patients had S-LAM. The mean level of sirolimus was 13 ng/ml after one-year treatment. Mean FEV1 at enrollment and end of study was 1000cc (33% predict) and 1228cc (42% predict) respectively (P=0.674). The mean FVC at baseline and end of study was 1648cc (49% predict) and 1866cc (55% predict) (P=0.996). The mean FEV1/FVC at enrollment and the end of treatment was 58% and 62% respectively (P=0.753). The mean FEF25-75 at first and at the end of treatment was 16% and 26%, respectively (P=0.028). The mean walk distance in 6MWT at first and at the end of study was 315 meters (P=0.9). The mean percentage of O2 saturation at rest was 84% and 92% at first and at the end of study (P=0.104). In LAM patients, sirolimus has been shown stabilizeto or improve lung function, rest and exertional O2 saturation. Sirolimus was effective in LAM patients who had severe or very severe physiological disorders.

The aim of this study was to use the volume of the graft as an adjunct tool for better decision making. Kidney transplanted patients with acute azotemia and documented volume and finally a biopsy were enrolled in this study . Graft volumes between rejected patients (antibody-mediated rejection {AMR} and cell - mediated rejection {CMR}) and non rejected but azotemic patients were compared. A total of 76 patients were enrolled in this study (45 case and 31 control ). 53.3% of the case group were (AMR) and 46.7% belonged to (CMR). There was no difference between kidney volume according to age or sex. But the case group had a significantly bigger volume than controls (253.09 cm3 and 186.45 cm3; p< 0.001). In addition, there was a significant difference between the volumes of AMR kidneys with CMR and controls (286.24+66.70 , 224.08+76.79 and 186.95+39.92; P=0.003 and p<0.001, respectively), but not between CMR and controls (P=0.067). A cutoff point of 200 cm3 was determined as rejection with sensitivity and specificity of 70% and a cutoff point of 250 cm3 could be used as AMR cut off with sensitivity of 76% and specificity of 70%. There was a significant difference in volume between rejection and control group and between AMR and CMR. So, kidney volume determination is an easy and valuable tool to help the clinician to have a more rapid and better decision making.

HbA1C has been a known predictor and diagnostic test for diabetes type 2. However, this test has not yet been widely studied in GDM and more importantly no cutoff point has been defined for HbA1C in GDM. We investigated the efficacy of screening during first and second trimester of pregnancy and defined appropriate cutoff points according to HbA1C and FBS for predicting maternal GDM among women with none to minimal previously known risk factors. This is a prospective multi-centered cohort study. Individuals were evaluated at first trimester, at 20-24 weeks and 24-28 weeks of gestation. GDM tests were done during visits and accuracy of each of these measurements was evaluated. Overall, 356 entered the study, among which 25 individuals and 30 individuals developed GDM during 20-24 and 24-28 weeks of gestation, respectively. HbA1C measured during first trimester at a cut-off of 5.35% predicted GDM of 24-28 weeks with an accuracy of 85.6%, sensitivity of 80%, and specificity of 80%. Furthermore, at a cut-off of 5.75% measured at 20-24 weeks, HbA1C predicted GDM with an accuracy of 94.5%, sensitivity of 97%, and specificity of 96%. Screening programs during first trimester and at 20-24 weeks of pregnancy, using HbA1C, can significantly aid in the early prediction of GDM, even among women with no to minimal previously known risk factors, which shows a need for revision in current guidelines.

C-reactive protein (CRP), creatine kinase-muscle (CK-MM) and aldolase A (AldoA) levels are predicted to be realistic biomarkers of osteoarthritic disorders (OADs). The objective of the study was to evaluate the levels of CRP, CK-MM, and AldoA and determine their correlations with risk factors such as inflammation, muscle degeneration, and skeletal muscle damage for OADs. Baseline data from 297 patients, average aged 60.17±7.19 years, suffering with OADs for 5.75±1.32 years and 315 participants, average aged 58.96±8.63 years, without OADs were collected in this cross-sectional study. Separate analyses were performed for the participants with and without OAD symptoms confirming with X-ray or MRI. Blood CRP, CK-MM, and AldoA levels were estimated. The receiver operating characteristic (ROC) curves, their respective 95% confidence intervals (CIs), and significance values were compared between participants with and without OADs to identify the risk factors for OADs in relation to biomarkers. In patients with OADs, who exhibited degenerative changes on musculoskeletal joints and risk factors based on the elevated levels of CRP, CK-MM, and AldoA having their mean±SD values, 7.22±6.09 mg/L,135.2±78.56 U/L and 8.09±2.15 U/L, respectively. Their respective values of areas under the curves (AUC) of ROC curves were 0.76, 0.68 and 0.91 respectively, of which all exhibited highly significant differences (p<0.0001) compared with the control subjects. It is concluded from the results that the elevated levels of studied biomarkers represent the predictive above-mentioned risk factors during OADs; therefore, monitoring CRP, CK-MM and AldoA levels may be an effective diagnostic method confirming with radiological imaging.

Aldosterone has been assumed to be implicated in left ventricular hypertrophy (LVH). Preventing the progression of LVH in the early period of end-stage renal disease (ESRD) can increase patient survival. In this study, therefore, we analyzed the relationship between aldosterone level and LVH in ESRD patients who underwent hemodialysis at Fatemeh Zahra Hospital and Imam Khomeini Hospital in Sari, Iran from 2016 to 2017. This research is a case-control study involving 69 patients, divided into the case group (n=52, exhibiting LVH) and the control group (n=17, no ventricular hypertrophy observed in the echocardiography). The relationship between the patients’ serum aldosterone levels and LVH was evaluated on the basis of relative wall thickness (RWT). Among the patients, 20.3% had normal cardiac conditions, 53.6% eccentric hypertrophy (EH), 4.3% exhibited concentric remodeling (CR), and 21.7% had concentric hypertrophy (CH). In other words, 24.6% of the patients belonged to the control group, and 75.4% belonged to the case group. The results indicated a significant difference (P=0.006) in average aldosterone levels between the case (165.11±80.8) and control (115.76±72.47) groups and a significant difference in aldosterone levels among the four subgroups (P=0.03), with the levels of the CH group being higher than those of the EH group. Based on the results of the study, a significant relationship exists between plasma aldosterone level and LVH in ESRD patients. Serum aldosterone level is therefore a predictor of LVH.

Breast cancer is the most common invasive cancer with high mortality in women all around the world. The present evidence shows that younger patients have poor survival. Thus, the aim of this study was to compare the pathologic characteristics of breast cancer in women younger than 40 years compared with older. This is a cross-sectional study which contains 681 patients with a confirmed diagnosis of breast cancer, who referred to Babolsar Shahid Rajaei Hospital as a referral cancer therapeutic center in the North of Iran. The data included age, residence area, occupation, location, histopathologic characteristics of the tumor, TNM classification and staging. The mean age (SD) of patients was 49.7 (11.9) years, of which 19.5% were under 40. Ductal carcinoma was the most common histopathologic type (90.0%) but patients at a younger age had a higher incidence of lobular and other rare carcinoma compared to the older ones (P=0.04). The younger had a greater tumor size (P=0.01), lymphatic node involvement (P=0.04) and higher staging (P=0.004). The younger age was not associated with positive estrogen/progesterone receptors. These findings indicated more aggressive tumor characteristics and serious breast cancer in women less than 40 years compared with older ones.

Hyperglycemia in diabetic people resulted in oxidative conditions. Propolis is the third most important component of bee products which has various functional properties such as anti-oxidant due to its components. The aim of this study was to evaluate the propolis effect on fructosamine level, the catalase activity, and the level of oxidized LDL changes in type 2 diabetic patients. In this double-blind, randomized controlled trial study, 62 type 2 diabetic patients, attending Endocrine clinic in Velayat Hospital (Qazvin, Iran) in 2017, were randomly assigned to one of intervention and placebo (n=31) groups. Participants in intervention group took propolis capsule (500 mg) 3 times a day and those in placebo group took placebo capsules for 8-week. Fructosamine level, catalase activity and the level of oxidized-LDL were measured at the baseline and at the end of the study. Statistical analysis was performed using SPSS software. At the end of the study, significant differences were seen within groups and in-between groups. In Propolis group compared to the placebo, fructosamine (p<0.05), and the level of oxidized LDL (p<0.05) decreased, and catalase activity (p<0.05) improved. However, there were no significant changes in the placebo group at the end of trial. Eight weeks intake of propolis as a supplement in type II diabetic patients could improve anti-oxidant defense and decline production of hyperglycemia induced products such as fructosamine.

Considering the importance of healthy diet in the protection of cardiovascular diseases (CVD), this research aimed to assess the physiological risk factors for CVD in middle-aged adults and their association with dietary intake in the north of Iran. In this cross-sectional study conducted in the years 2016-2017 among the adults aged 40-60 years living in Amirkola, Babol, the participants´ physical activity, dietary intake, body mass index, fat mass, blood pressure, fasting blood glucose and serum lipid profile were reported. The International Physical Activity Questionnaire was used to assess physical activity and a structured 24-hour food-recall questionnaire was used to assess the participants´ dietary intake. Consumed foods and beverages on two separate days were analyzed and transcribed in 10 food groups (gram). Two hundred and ninety-one persons (96.7%) had complete participation, 96.2% with at least one CVD risk factor and 75.9% had overweight or obesity; 33% with hypertension; 6.2% had high fasting blood glucose; 64.6% with hypercholesterolemia, 47.8% had hypertriglyceridemia, and 8.9% with low HDL. Mean daily intake values of carbohydrate, protein and fat were all higher than dietary reference intakes for adults. Physical activity less than 1500 MET-minutes per week was significantly associated with having three or more physiological risk factors for CVD [adjusted odds ratio: 2.04 (1.08-3.85)] (P=0.029). Most of the middle-aged adults in this region had at least one of the physiological risk factors for CVD and daily intakes of carbohydrate and protein were higher than dietary reference intakes (DRIs) for adults.

Systemic lupus erythematosus (SLE) is an autoimmune disease that is characterized by T-cells imbalance. There are ongoing controversies about the role of specific T-helper cell subsets and their cytokines. The study aimed to confirm the disturbance of Th17/Treg ratio in SLE patients. Subjects were SLE patients who met the American College of Rheumatology 1997 criteria. Disease activity assessment was measured by SLAM index. Th17 and Treg level was measured by flow cytometry. Th17 level was evaluated as CD4+L17 whilst Treg as CD4+Foxp3+. Final result is stated as Th17/Treg ratio. Thirty female subjects with active SLE had mean SLAM Score of 29.3±3.88, C3 level 25.2 (6-59.5), C4 level 15.25 (5-54.3), ESR 62.1±37.85, CRP 30.16±59.45, and anti-dsDNA 155.32±186.10. Higher Th17 level was found in SLE patients compared to healthy subjects (30.09 pg/ml vs 13.01pg/ml; 12.60% vs 0.91%). However, it did not correlate to disease activity (p>0.05; r=-0.28). Regarding Treg level, there was no significant difference between active SLE and healthy subjects (12.85 vs 11.05 pg/ml; 9.57% vs 2.05%). Treg level negatively correlated to SLE disease activity (p<0.01; r=-0.73). Th17/Treg ratio was 3.28±2.22% and it positively correlated to SLE disease activity (p<0.01; r=0.78). Th17/Treg ratio is positively correlated with disease activity. Th17 level is elevated but not correlated with disease activity. Decrease of Treg level is not significant though correlated with disease activity in SLE patients.

Bloodstream infection with Candida, or candidemia, is the most common Candida systemic infection. In this study, we investigated the characteristics of patients with candidemia to provide appropriate perspectives on these patients and reduce the associated mortality and morbidity. In this cross-sectional study, all patients with at least one positive blood culture of Candida spp. were investigated from April 2015 to March 2016 in Imam Khomeini Hospital Complex, Tehran, Iran. A total of 74 patients (44 men and 30 women), with the mean age of 53.15±17.89 years, were enrolled in this study. Non-albicans Candida species was responsible for candidemia in 67.6% (50.74). The mean therapy intervals were 7 and 5.6±1.5 days in patients who died and were discharged, respectively. The differences in frequencies of urinary catheter and mechanical ventilation were statistically significant among patients who died and survived (P<0.001). Among the discharged patients, antifungal therapy was administered to 30.8% (12.39). The mortality rate was 54.3% (19.35) in the medical ward, 5.7% (2.35) in the surgical ward, and 40% (14.35) in the intensive care unit (P=0.041). The treatment was significantly associated with lower mortality than those with no treatment (OR=0.150 [0.023-0.996], P=0.05). The number of candidemia cases caused by non-albicans Candida species is continuously increasing in our center. We demonstrated the epidemiologic characteristics of patients with candidemia and the significant effects of timely and appropriate treatment on their outcomes. Further studies are needed to illuminate more aspects of this healthcare problem

Evidence suggests hypovitaminosis D is associated with increased risk of coronary artery disease (CAD) and its extent and related risk factors. However, some investigations have produced contrary results. Therefore, we aimed to evaluate the association between serum vitamin D levels and the severity of premature coronary artery involvement. This randomized prospective, case-control study was conducted in Babol from April 2013 to June 2017. We collected the demographic data and measured serum 25-OH-D levels of 294 patients (age≤50 years) diagnosed with CAD with coronary angiography as case group as well as 438 age and sex-matched controls. CAD severity was assessed using the Gensini score. Statistical analyses were used to assess the associations and p<0.05 was considered as significant. The mean serum level of 25-OH-D was 13.12±11.13 and 18.28±8.34 in case and control groups, respectively (P=0.036). In the case group, mean serum vitamin D levels were significantly lower among hypertensives (P=0.018), those with a family history of CVD (P=0.016) and those who used aspirin (P=0.036). The mean Gensini score of patients in the case group was 45.02±23.62 and was higher among men (P=0.022). There was a weak significant correlation between the serum vitamin D levels and the Gensini score (P=0.001 & R=-0.543). The mean Gensini score was not significantly different between patients with deficient (47.02±22.78), insufficient (26.0±21.72) and sufficient (39.0±43.84) vitamin D levels (P>0.05). The results showed that the lower levels of vitamin D is associated with increased risk and extent of coronary artery involvement as well as some of the risk factors of CAD, including male gender, hypertension and positive family history for CVD.

Cardiovascular diseases are global problems. They are causes of death in about 43% of people worldwide and may become the most widespread reason of death by 2020. The prognosis is directly dependent to immediate diagnosis and on time treatment. Introduction of new biochemical markers as the early diagnosis of complications after coronary revascularization is very important in this period. Herein, we assayed the changes of purine catabolites in patients with acute coronary syndrome (ACS) before and after percutaneous coronary intervention (PCI) in comparison with control group. Thirty five ACS patients (20 males and 15 females) were included (57±17 years old) in the study. The determination of intermediates of purine catabolism as guanine, hypoxanthine (GCS), adenine, xanthine (Kc) and uric acid (MK) were assayed before and 3 days after PCI. Conditionally, 35 healthy-matched persons were included in the control group. Purine catabolites were determined in plasma through the method of Oreshnikov E.V (2008). In ACS patients, prior to PCI, there was a tendency to increase the concentration of guanine (P=0.001), hypoxanthine (P=0.002) adenine (P=0.0003), xanthine (P=0.000003) and uric acid (P=-0.000001) relative to the upper limits of normal ranges. And on the third day after PCI, there was the second tendency to increase the levels of guanine (P=0.000001), hypoxanthine (P=0.000001) adenine (P=0.0000001), xanthine (P=0.000001) and uric acid (P=0.0000001) relative to upper limits of normal ranges. Increment of plasma purine catabolites can be a marker of inflammation and instability of coronary artery plaques and may be used as a restenosis marker in patients with history of PCI.

The present study aimed to evaluate serum YKL-40 levels in patients with rheumatoid arthritis (RA) compared to healthy subjects and to search whether there is an association between YKL-40 levels and disease characteristics in RA. In this cross-sectional study, 60 RA patients based on the ACR/EULAR 2010 criteria and 30 age- and sex-matched healthy controls were included. In patients, clinical examination was performed and disease activity score 28 (DAS-28) measure of disease activity was assessed. Serum YKL-40 level was measured using ELISA kit. The mean±SD age of patients and controls was 54.86±11.65 and 50.71±3.72 years, respectively). Serum YKL-40 level was significantly higher in RA patients (951.63±639.98 pg/mL) compared to healthy controls (444.92±150.37 pg/mL) (P<0.001). There was no significant difference in serum YKL-40 level according to the activity of disease (p>0.05). There were significant positive correlations between serum YKL-40 level with disease activity (r=0.347, P=0.007) and rheumatoid factor (r=0.396, P=0.002). There were no significant correlations between serum YKL-40 level with demographic characteristics as well as biochemical measurements including serum creatinine, blood urea nitrogen, erythrocyte sedimentation rate, C-reactive protein and anti-cyclic citrullinated peptide. Our study revealed higher serum YKL-40 levels in RA patients compared to healthy controls, which correlated positively with disease activity. Therefore, YKL-40 can be considered as a novel biomarker for disease activity estimation in RA.

Labor is a natural pain despite the fact that the severity of the pain and response to it differ in various people, but most women refer to labor as an unpleasant experience of their lives. The present study was carried out to determine the effect of honey on the severity of labor in primigravida women. In this study, 80 healthy volunteer primigravida women were entered to the research as randomized clinical trial (40 subjects in each group) after studying and signing consent form and they were randomly divided into two intervention honey group and control group. The data gathering tool comprised four main parts of the personal profile questionnaire, controls performance in the labor, records fluid intake rate and pain intensity using a 0-10 cm ruler. The mean of pain intensity in the honey syrup intervention group was significant. Honey syrup consumption without side effects significantly affected the severity of labor.

Fever of unknown origin (FUO) is a perplexing medical problem. The causes for FUO are more than 200 diseases. The aim of the study was to present human clinical cases of Coxiella burnetii infection debuting as FUO. The following methods were conducted in the study: literature search, laboratory, imaging, and statistical methods. Criteria of Durack and Street were applied for FUO definition. For the etiological diagnosis indirect immunoenzyme assay (ELISA) for antibodies detection against Coxiella burnetii was used (cut-off = 0.481–0.519). From 2008 until 2015, nine patients with FUO caused by C. burnetii were hospitalized at the Military Medical Academy of Sofia. Male gender was predominant (male/female – 77.8% /22.2%), mean age was 48.78±14.52 years (range: 26–67), hospital stay was 9.78±2.95 days (range: 5–15), fever duration was 54.33±56.23 days (range: 21–180). Laboratory investigations estimated the elevation of erythrocyte sedimentation rate 49.11±31.74mm/h (95%CI = 13.09–111.31), C-reactive protein 37.68±37.62mg/L (95% CI = 36.07–111.42) and fibrinogen 5.69±1.59g/L (95% CI=2.57–8.81). The mean values of liver enzymes were in reference range. Among imaging tests, abdominal ultrasound and X-ray demonstrated 33.3% contribution to the final diagnosis. Transthoracic echocardiography found 22.2% contribution. Serological methods presented 100% contribution. C. burnetii infection was accepted as a final diagnosis among 9 patients with FUO based on the integrated information from the applied methods. Active search and establishment of this pathogen among FUO should lead to avoiding potential complications and consequences in case of untreated patients infected with C. burnetii.

Neurofollicular hamartoma (NFH) is characterized histopathologically by fascicles of spindle cells that laterally delimited by hyperplastic folliculosebaceous units. It usually appears on face, near the nose or nasolabial fold. It does not manifest true neural differentiation and recently the term spindle cell predominant trichodiscoma (SCPT) has been used instead. We present a case of a 40-year-old male with co-incidence of NFH and basal cell carcinoma (BCC) that the mesenchymal components of NFH were similar to SCPT but these components highly expressed S-100 protein. We also discuss about the histological aspect of the neoplasia in this report and consider the findings of other reports in association with classification of NFH by means of cellular markers and morphological resemblance to other skin hamartomas. Neurofollicular hamartoma is a rare benign tumor that thought to represent the cellular end of a morphological spectrum with trichodiscoma. The morphological features and expression of S100 protein in neural element helped us to achieve the diagnosis of neurofollicular hamartoma. However, variable reports of S-100 protein expression in NFH are available and further studies are needed to determine the classification of this tumor.

Neurofollicular hamartoma (NFH) is characterized histopathologically by fascicles of spindle cells that laterally delimited by hyperplastic folliculosebaceous units. It usually appears on face, near the nose or nasolabial fold. It does not manifest true neural differentiation and recently the term spindle cell predominant trichodiscoma (SCPT) has been used instead. We present a case of a 40-year-old male with co-incidence of NFH and basal cell carcinoma (BCC) that the mesenchymal components of NFH were similar to SCPT but these components highly expressed S-100 protein. We also discuss about the histological aspect of the neoplasia in this report and consider the findings of other reports in association with classification of NFH by means of cellular markers and morphological resemblance to other skin hamartomas. Neurofollicular hamartoma is a rare benign tumor that thought to represent the cellular end of a morphological spectrum with trichodiscoma. The morphological features and expression of S100 protein in neural element helped us to achieve the diagnosis of neurofollicular hamartoma. However, variable reports of S-100 protein expression in NFH are available and further studies are needed to determine the classification of this tumor.