Tanaffos Respiration Journal
Volume:17 Issue: 3, Summer 2018

Asthma is considered as a complex disorder in which genetics and environment play crucial role in its susceptibility. In addition to the huge financial costs that significantly reduce the quality of life of the patients and their families, it causes high prevalence of lung diseases. Finding contributing new genetic factors involved in early diagnosis or progression of asthma can provide novel approaches for treatment or managing of asthma. In the present study, the potential role of two key cytokines of IL-10 and IL-17A was investigated in asthma pathogenesis. Using real-time PCR technique, we analyzed the expression levels of target genes in two groups of mild and severe asthma patient in comparison with healthy individuals. In comparison with control population, obtained data showed 4 and 7-fold down-regulation of IL-17A in the group of mild and severe asthma, respectively. Down-regulation of IL-17A showed a significant correlation with progression of asthma severity. While IL-10 showed up to 10-fold down-regulation in the group of severe asthma, its expression level was not correlated with severity of asthma. Obtained data revealed that deregulation IL-10 and IL-17A have potential to play crucial role in pathogenesis and prognosis of asthma. Observed down-regulation of these cytokines in blood cells suggests their usefulness as a marker in diagnosis of asthmatic types in patients. Key words: Asthma; Cytokine expression; IL-17A; IL-10; PBMC, qPCR

Nowadays, the most practical approaches used to treat sleep apnea, are Continuous Positive Airway Pressure (CPAP), Bi-level Positive Airway Pressure therapy (BPAP), supplemental O2, servoventilation and/or a combination of these approaches simultaneously. However, each leads to different consequences in opioid related Central Sleep Apnea (CSA) patients. Given the high prevalence of CSA and frequently use of opioids worldwide, it seems that evaluation of the condition in these patients is required to determine their responsiveness to the above mentioned treatments and to choose the most appropriate therapy. This longitudinal cross-sectional study included 41 opioid related CSA patients who underwent a step-by-step protocol (including CPAP, CPAP + O2 and BPAP) in which if the patient was nonresponsive to a treatment, the next therapy was applied. If the patient was nonresponsive to all of these approaches, only oxygen was administered. Finally, the collected data were analyzed with SPSS software (ver. 22). Among 41 participants, the responsiveness to CPAP, CPAP+O2 and BPAP were 41.5%, 14.6% and 39%, respectively versus 4.9% nonresponsive patients to all above mentioned therapies. In patients with CSA and opium addiction, the CPAP and BPAP were the most effective treatments. In this group of patients, better response in the presence of higher Apnea–Hypopnea Index (AHI) was observed to BPAP, whereas better response in patients with lower AHI was to CPAP+O2 Accordingly, CPAP and BPAP are successful approaches to treat opioid related CSA patients in various medical conditions including long-run addiction course, concurrent smoking and addiction but it appears that further studies are essential. Key words: Central sleep apnea; Continuous positive airway pressure; Bi-level positive airway pressure; Supplemental O2, Addiction

Bronchial anthracosis is the black discoloration of bronchial mucosa that exhibits similar manifestations to Chronic Obstructive Pulmonary Disease (COPD). The etiology of this obstructive lung disease has not been elucidated and standard therapy for this disease has not been introduced in the literature. The objective of this study is to determine the efficacy of the salmeterol-fluticasone inhaler and tiotropium as two safe treatments of obstructive lung disease for the treatment of symptomatic subjects of anthracofibrosis of the lung. Twenty anthracofibrosis subjects who suffered from dyspnea were enrolled in this three-phase, cross over, placebo-controlled clinical trial. The primary outcome variable was quality of life (evaluated with the CAT questionnaire). Clinical findings and spirometry were the secondary outcome variables. Both of these drugs were delivered by an inhaler and were made identically by the reference manufacturer. Salmeterol-fluticasone was prescribed with a spacer and tiotropium by its special device, and the method of utilization was taught to the patients. Twenty anthracofibrosis subjects were enrolled in this three-phase, five-month course of treatment with either salmeterol-fluticasone or tiotropium inhalers. The response to therapy was not good; neither for salmeterol-fluticasone nor for tiotropium in the short course of the treatment. However, the overall results of 5 months of therapy with both of the drugs have shown improvement in 57% of the subjects. The most prominent results were found in the CAT score [25.1±5.54 before the trial, which decreased to 19.2±5.14 (Z score=2.7, P=0.007)] and clinical findings especially sputum, chest pain, and wheezing (81, 94 and 92% before the trial and 50, 56, 54% after the trial, respectively). Neither clinical findings nor spirometry was able to predict a good response to salmeterol-fluticasone or tiotropium. The combination of salmeterol-fluticasone and tiotropium inhaler was able to improve the clinical findings of symptomatic anthracofibrosis patients. Key words: Anthracofibrosis; Anthracosis; Treatment; Salmeterol; Fluticasone; Tiotropium

When potential brain dead donors are in line-up for organ retrieval, their loss would be such a disaster. The aim of this study was to detect the occurrence of different disorders leading to pre-retrieval donor’s cardiac arrest and loss in order to prevent this energy and money wasting challenge. In this observational study, medical records of potential donors from 2001 to 2016 who were lost after transfer to Organ Procurement Unit (OPU) of Masih Daneshvari Hospital and before organ donation were reviewed and weigh of every responsible disorder was tested. Equal number of actual organ donors were randomly selected others for comparison. In 14 years of experience in organ donation, 46 (3.09%) out of 1485 potential donors were lost after their transfer to OPU with the aim of organ donation. Mean age of donors and their gender were not significantly different to actual donors (37.4 ± 17.7 versus 39.2 ± 18.4, P= 0.2). However, proportion of drug toxicity as the cause of brain death was more common in the lost donors (19.5 versus 5.3%, P= 0.001). Thirteen (28.2%) of the cases had a documented history of ischemic heart disease, which was not as common in actual donors. After excluding hypotension and diabetes insipidus, more incident disorders among the lost donors were metabolic acidosis, hypocalcaemia, hyperglycemia, thrombocytopenia, severe anemia and different presentations of coagulopathy. Clinical conditions of 47.8% of cases were flared up by different severities of acute kidney injury and mean ALT levels were significantly higher than actual donors. All the above mentioned disorders were significantly more common in lost donors than actual ones. Drug toxicity, history of ischemic heart disease and occurrence of acute kidney injury are associated with more potential donors’ loss before organ retrieval. Key words: Organ donation, Brain death, Diabetes insipidus, Deceased donor

Thymoma is the most common tumor of the anterior mediastinum that has the most effective treatment, as it can be completely resected. In patients with advanced stage, phrenic nerve involvement can be seen and suggested treatment for these patients is unilateral phrenic excision and diaphragm plication. However in patients with myasthenia gravis, there are concerns in relation to this method of treatment. The aim of this study is to evaluate the effects of plication of the diaphragm on complications of phrenic nerve excision in thymoma patients with and without myasthenia gravis involving the phrenic nerve. A retrospective cohort study was performed on 26 patients with thymoma; half of the patients had myasthenia gravis and the other half did not have myasthenia gravis. We performed diaphragm plication in 7 patients in each group with excision of phrenic nerve. Patients were evaluated based on preoperative and postoperative variables. The patients’ age (P=0.943), sex (P=0.999), blood loss during surgery (P=0.919), need for transfusion during surgery (P=0.999), short term complications (P=0.186), need for tracheostomy (P=0.27) and mortality (P=0.09) differences were not significant. However, the average duration of ICU stay (P=0.001) and intubation in ICU (P=0.001) in patients who had myasthenia gravis was more than patients without myasthenia gravis. These values were less in patients with myasthenia gravis and diaphragm plication than patients with myasthenia gravis and no diaphragm plication. Excision of the phrenic nerve in patients with myasthenia gravis associated with thymoma and phrenic nerve involvement is appropriate. Key words: Plication, Diaphragm, Phrenic nerve, Thymoma, Myasthenia gravis

Antimicrobial stewardship program is a comprehensive, longitudinal program designed to improve and measure the appropriateness of antimicrobial use while increasing patients safety, decreasing cost of patients care, and combating emerging antimicrobial resistance. Antimicrobial resistance, specially emerging multidrug-resistance and extremely drug-resistance gram negative bacteria, is an important concern in the modern world. This is particularly problematic since antimicrobials in production pipelines are not meeting the demand for the emerging resistance micro-organisms; in another word "we are running out of options". Indiscriminate use of antimicrobial may increase the risk for resistance, and drug toxicity. The aim of this study is to implement an evidence-based antimicrobial stewardship program in a tertiary referral hospital. This study will assure consistency of the stewardship program and measure outcomes to further assess the effectiveness of this program. After establishment of antimicrobial stewardship committee and endorsement of policies the program will be conducted in all hospital medical wards. In an observational study, all patients receiving antimicrobials included in the program will be closely monitored for primary and secondary outcomes. Hospitals antimicrobial resistance patterns are monitored periodically to assess improvement. The quality indicators will be assessed to ensure proper execution of the program over time. As a study protocol, there are no results available to be reported at this time. We are expecting to observe significant reduction in cost of antibiotic use shortly after program execution. By more appropriate utilization of antibiotics patients safety will be increased. Furthermore, we are expecting to detect improvement in antimicrobial resistance patterns. Key words: Antimicrobial stewardship, Appropriateness, Resistance

The Human Immunodeficiency Virus (HIV) has long been known to alter the clinical presentation of tuberculosis (TB), which varies according to the time of occurrence of TB infection and the level of immunodeficiency. Identifying variations in clinical features in HIV-TB coinfection might be helpful in settings with limited diagnostic facilities. The aim of this study was to assess the clinical presentation of TB in HIV coinfection and associate clinical findings with level of immune suppression (CD4 count). In this prospective, cross-sectional observational study 110 patients having TB-HIV co-infection were assessed for clinical presentation and correlation with CD4 count. The study setting was a tertiary care teaching hospital. Patients were categorized in three group based on CD4 counts as group I: ≤ 100 cells/cmm, group II: 101-200 cells/cmm and group III: > 200 cells/cmm. 110 patients were enrolled, 70% had CD4 cell count < 200 cells/mm3. Mean age and CD4 cell were 33.82±8.79 years and 181.7cells/cmm, respectively. Most common form of tubercular involvement was pulmonary (56.4%) followed by combined pulmonary and extra-pulmonary involvement (28.2%) and exclusively extra-pulmonary (15.5%). No significant intergroup difference was observed in site of involvement among three groups (p=0.700). Cough (91.8%) followed by low grade fever (85.5%), anorexia (82.7%) and weight loss (66.4%) were the commonest presenting symptom without any significant inter group difference. 70.9% patients were in undernourished category and 53.6% were febrile on examination. Sputum negative TB was noted 53.8%. 72.0% of patients with CD4 counts ≤100 had sputum negative TB as compared to sputum positive TB (28%). Due to varied clinical presentation of TB in HIV patients, ample knowledge of the clinical spectrum at different levels of immunosuppression is absolutely necessary to identify such patients early. Key words: HIV infection, TB, Clinical presentation, Immune-suppression, Acid Fast Bacilli

Tuberculosis caused by Mycobacterium tuberculosis (M. tuberculosis), remains as one of the leading causes of deaths worldwide, with nearly two million death cases annually. BCG (Bacille Calmette-Guerin) continues to be the most widely used vaccine in the world, but the protective immunity differs in different parts of the world. Accordingly, new strategies including DNA vaccines are essentially needed. This study was aimed to design and construct a cloning vector containing mpt64 gene of M. tuberculosis. M. tuberculosis H37Rv was cultured on Lowenstein Jensen medium, and genomic DNA was extracted. The mpt64 gene was amplified by PCR using designed specific primers. After the digestion of mpt64 and pcDNA3.1 (+) by BamHI and EcoRI restriction enzymes, the mpt64 fragment was ligated into the digested vector using T4 DNA ligase enzyme. Then, the recombinant vector was transformed into competent Escherichia coli (E. coli) TOP10 strain. To confirm the colonies of transformed bacteria, antibiotic resistance, colony-PCR, restriction enzyme digestion and DNA sequencing were used. To confirm the clones, colony-PCR using mpt64 specific primers was performed and the fragment of 718 bp was observed by gel electrophoresis. Clones were also verified by restriction enzyme digestion using BamHI and EcoRI restriction enzymes and the 718 bp fragment was observed. Furthermore, results of DNA sequencing showed 100% homology with the mpt64 fragment of H37Rv in GenBank. In this study, the mpt64 fragment was successfully cloned in pcDNA3.1 (+) vector. This construct can be used in future studies as a DNA vaccine in animal models to induce immune system responses. Key words: Mycobacterium tuberculosis, DNA vaccine, cloning vector, mpt64

Pneumocystis pneumonia (PCP) is a common opportunistic infection in immunocompromised patients. In general, clinical response to therapy with cotrimoxazole is excellent. However, therapy may be limited by side effects or treatment failure. We present a case of PCP in a 35-year-old male patient with history of heart transplantation and renal failure who was admitted with a 10-day history of fever, nonproductive cough and elevated level of creatinine with a diagnosis of PCP confirmed by chest radiography and in bronchoalveolar lavage specimens. He was treated with trimethoprim-sulphamethoxazole (SMZ/TMP) and primaquine but treatment was completed with reduced dosage of cotrimoxazole, primaquine and with the addition of caspofungin. This therapy was effective and without any adverse effects in a patient with elevated level of creatinine. Key words: Pneumocystis Pneumonia, Chronic renal failure, Caspofungin

Renal transplantation is among the definitive therapies for treatment of patients with “End-Stage Renal Disease” (ESRD). Proper anesthesia should be considered in patients who undergo renal transplantation. On the other hand, anesthesia in patients with single lung is an ever challenging issue. In this case report, we introduce a 42 year old woman with “Autosomal Dominant Polycystic Kidney Disease” (ADPKD) who was candidate for renal transplantation and underwent regional anesthesia since she had one lung. The patient had bilateral renal resection 4 years ago (due to ADPKD) and was undergoing dialysis 3 times weekly. Thirty five years ago, left lung resection had been done for the patient (due to suspected Tuberculosis). This patient demonstrated our experience in management of regional anesthesia as a safe method in patients with single lung who would undergo renal transplantation. Key words: Regional Anesthesia; Renal Transplantation; Single lung