Tanaffos Respiration Journal
Volume:9 Issue: 1, Winter 2010

The pandemic influenza A (H1N1/2009) virus as a new challenge for health care providers has caused significant morbidity and mortality worldwide. Although many aspects of this virus are similar to other human influenza viruses, there are some disparities. This article reviews different aspects of influenza H1N1/2009 virus with focus on clinical features and management of patients

Thyroid masses are common, especially in areas of iodine deficiency. Mediastinal goiter is defined by the presence of enlarged thyroid tissue below the level of the thoracic inlet. This study aimed to evaluate the presentation, diagnosis, treatment, histopathological findings and complications of patients with mediastinal goiter or masses. This was a descriptive cross-sectional chart review study of patients with substernal goiter or masses who underwent cervical and mediastinal thyroidectomy from March 2003 to February 2007. From a total of 470 patients admitted for thyroid surgery, 60 cases (12.7%) presented with substernal extension of goiter or masses during the study period; 88% of patients were females with a mean age of 46.77±10.77 yrs. Cervical masses were the most common preoperative presentation (78%), followed by compressive symptoms (67.8%); 5.08% of cases were asymptomatic. In 10%, the goiter or masses were located in the posterior mediastinum. Total thyroidectomy was performed in 59% of patients mostly by low collar incision. Sternotomy or thoracotomy was required in three patients (5%) mainly because of mediastinal masses or invasion of carcinoma. Postoperative complications included transient hypocalcaemia (46%) and persistent recurrent nerve paralysis (3.4%). There was no mortality. Histopathologically, 18.5% of masses were malignant; mostly papillary carcinoma. Presence of substernal goiter or masses is an indication for early surgery, even in asymptomatic or elderly patients. These masses have progressive enlargements and carry a high risk of tracheal compression.

Ventilator-associated pneumonia (VAP) has been reported as the most common hospital-acquired infection among patients requiring mechanical ventilation. This study aimed to determine the incidence of ventilator-associated pneumonia in a cardiopulmonary tertiary center, and to evaluate its etiology, resistance patterns, and outcome of admitted patients. In a retrospective study, patients admitted to the Masih Daneshvari Hospital, a tertiary cardiopulmonary center, were evaluated in a 7-month period. A total of 530 patients were admitted to the ICU out of which, 40 acquired VAP. Overall, 99 patients were evaluated (male= 57, female= 42) including 40 VAP and 59 non-VAP cases. The incidence of VAP was estimated to be 7.5% in this unit. The underlying conditions included respiratory diseases (COPD, asthma, etc), and cardiac problems (post "coronary artery bypass graft" CABG, etc). Also, patients in the thoracic surgery ward and those with renal, gastrointestinal, neurologic and other medical problems were evaluated. The patients were divided into two groups of VAP and non-VAP cases. The micro-organisms were recovered from the patients’ bronchoalveolar lavage fluid. The most common micro-organisms recovered were Pseudomonas aeruginosa (17 cases) and Staph. aureus species (15 cases). In VAP patients in whom S. aureus was recovered, 80 percent of species were methicillin-resistant (MRSA) but all were sensitive to Vancomycin. Moreover, resistance to two, three or four antibiotics was seen in 12, 10, and 5 patients, respectively, in whom P. aeruginosa was recovered. The prevalence of S. aureus in patients with respiratory problems was more than other groups (including MRSA species). But the prevalence of recovered P. aeruginosa was the lowest in respiratory patients, compared to other groups. Also the mortality rate in drug resistant S. aureus and P. aeruginosa groups were 42 and 47 percent, respectively. Length of stay for MRSA group was 80% and death rate was 50%. In P. aeruginosa group, there was a positive relationship between resistance to multiple drugs and mortality and also ICU stay. VAP is a common infection in ICU setting and certain interventions may affect its incidence. In our study, P. aeruginosa and S. aureus were more common in ICU patients. Pseudomonas species were associated with the highest mortality rate and were resistant to four antibiotics in the antibiogram testing. S. aureus species were more common in patients with underlying respiratory problems, compared to those with other Tanaffos

Chronic obstructive pulmonary disease (COPD) is a progressive chronic disease and C-reactive protein (CRP) and fibrinogen are considered as main systemic inflammatory biomarkers. This study aimed to evaluate the alterations of CRP and serum fibrinogen levels in COPD patients and their correlation with the severity of disease, arterial O2 saturation and opium or cigarette consumption. This was a descriptive case-control study conducted on 31 COPD patients and 29 healthy controls selected by using easy sampling method in Afzalipour Hospital. Serum levels of CRP and fibrinogen were measured by ELISA method and analyzed using SPSS software version 15. The mean serum level of CRP in the understudy patients (13.15±13.72 mg/L) was significantly higher than that of the controls (3.53±1.12 mg/L)(P=0.000). However, no significant difference was found in the mean serum level of fibrinogen between cases (3.81±0.93 mg/dl) and controls (3.72±0.9 mg/dl)(p=0.82). Also, no significant correlation was detected between the serum level of CRP or fibrinogen and severity of the disease (P=0.92 and P=0.58, respectively). A statistically significant relationship was found between the serum levels of CRP and fibrinogen and arterial O2 saturation (P=0.02). There was no significant difference in the serum levels of CRP and fibrinogen between the opium users (p=0.19) and other patients (p=0.15). According to our study results, COPD, per se, can increase the inflammatory biomarkers including CRP. Raised serum level of CRP is indicative of systemic inflammation which results in extra-pulmonary manifestations like cardiovascular diseases, cerebrovascular accidents, osteoporosis, and cachexia. Therefore, with routine measurement of this marker, we can evaluate the severity of systemic inflammation in these patients and choose the best treatment accordingly.

The risk of pulmonary complications after esophagectomy is higher than after any other common operation, including major lung resection. In this study, we sought to identify risk factors associated with the development of pulmonary insufficiency requiring mechanical ventilation to identify preoperative parameters involved in the estimation of the risk of pulmonary insufficiency. We performed a retrospective cohort study on consecutive patients undergoing esophagectomy for malignancy in the Thoracic Surgery Department of Modarres Hospital in Tehran from March 2002 to February 2006. Patients were assigned into two groups based on whether they required mechanical ventilation or not. Preoperative, operative, and postoperative data were compared among the two groups. To find predictive variables for requiring mechanical ventilation, backward stepwise regression analysis was carried out with risk factors as independent variables and the need for ventilatory support as the dependent variable. The study population included 77 males and 43 females with a mean age of 60.16±12.04 years (range 29–79 years). Twenty-seven patients (27.7%) required mechanical ventilatory support. Multivariate analysis revealed sex (Odds ratio: 4.590, CI 95%: 1.248-16.411) as a confounder and duration of operation (Odds Ratio: 1.677, CI95%: 1.102-2.533) as a risk factor for requiring mechanical ventilation. Proper patient selection for esophagectomy is important for reducing the postoperative mortality and morbidity and benefiting from a radical resection.

Smoking is among the most common preventable causes of early death in the world. Implementation of smoking cessation programs is among the effective strategies of tobacco control. More than half the smokers experience nicotine withdrawal syndrome after quitting and this could be one of the main reasons of unsuccessful smoking cessation. This study evaluated the severity of nicotine withdrawal symptoms 14 days after quitting (the last visit of smokers to the smoking cessation clinic). This was a cross sectional study conducted on volunteers for smoking cessation from Nov. 2006 to Nov. 2007. During a one month course, volunteers attended 4 sessions of treatment and training (1 session per week). Since the 2nd session, they stopped smoking with the aid of nicotine gum and behavioral therapy under the supervision of a physician. Fourteen days after quitting (4th session), the severity of nicotine withdrawal symptoms was evaluated using the Minnesota test and was compared between males and females using the Chi square test. A total of 197 participants were studied, 65% of which were males, 76.6% were married, 49.2% successfully quit smoking during the study period, 12.2% cut down smoking, and 38.6% did not finish the course. The mean score for increase in appetite, irritability and depression was 4.6±3.4, 4.3±3.4 and 3.6±3.3, respectively. The mean score for severity of depression was 4.5±3.4 in women and 3.19±3.2 in men (p=0.03). The mean score for severity of anxiety was 4.6±3.6 in women and 2.6±2.9 in men (p=0.004). Also, the mean score for severity of irritability was 5.7±3.3 and 3.6±3.3 in women and men, respectively (p=0.002). The severity of symptoms related to nicotine withdrawal syndrome was considerably low 14 days following abstinence. However, the severity of nicotine craving was significantly higher compared to other symptoms. Severity of more than half the symptoms was significantly higher in women but further investigations are required in this regard.

According to the World Health Organization (WHO) report in 2008, incidence of tuberculosis in Iran is 25-49/100,000 cases per year. Based on the guidelines of the Ministry of Health, case detection index for smear positive pulmonary tuberculosis (SPP-TB) has reported to be 11/ 100,000 in Iran in the year 2006. Sistan and Baluchestan Province has the highest rate of SPP-TB in Iran. This study aimed to evaluate the trend of incidence of SPP TB from 2005 to 2008,taking into consideration the interventions (started in the beginning of 2006) implemented by the Zahedan University of Medical Sciences to reinforce the screening system and evaluate the case detection index in this province. The understudy population comprised of the whole community under medical coverage of Zahedan University of Medical Sciences. Screening was mainly conducted passively till the end of 2005. Since the early 2006, some interventions have been conducted to reinforce the active screening system. All the information regarding the new cases of SPP-TB from 2005 to 2008 was collected from the Center for Disease Control of Sistan and Baluchestan Province. Changes in trend of SPP-TB incidence were analyzed by using Time Series analysis considering the interventions and related effective factors. As a result of interventions aiming at reinforcing active screening since 2006, there has been a significant increase in both the incidence rate and case detection index. However, the incidence rate decreased in 2007.By using "Time Series Analysis for evaluation of the trend of incidence during the study period, the incidence of TB was estimated to be 22.88 cases in 100,000 in 2009. If we overcome the existing shortcomings regarding the screening system of SPP TB, successful case detection index should be higher than 22.88 in 100,000.

This study aimed to present four children suffering from recurrent pulmonary infections in the context of hyper IgE syndrome. All patients had recurrent pulmonary infections including pneumonia, bronchiectasis, pulmonary abscess and hydropneumothorax. Serum IgE level was greater than 2000 IU/ml in all cases. Microbial cultures showed Staphylococcus aureus and Pseudomonas aeruginosa in two cases. All responded well to the wide spectrum intravenous antibiotics. Extra-pulmonary manifestations included purulent lymphadenitis as well as skin and brain abscesses.Hyper IgE syndrome causes recurrent pulmonary and extra-pulmonary infections which respond fairly well to wide spectrum antibiotic therapy.

We present a case of a 65 year-old female who admitted with fever and a small infiltrate on the chest x-ray. CT-scan showed presence of a well-circumscribed solitary mass. She underwent surgical resection which showed presence of a granular cell tumor.Clinical and pathological features of granular cell tumor will be described in this report.

Anthracosis of the lung is black discoloration of bronchial mucosa that may distort and occlude the bronchial lumen and cause significant clinical findings named "Anthracofibrosis". In this article a rare presentation of this disease and related complications were reported. A 73 year-old woman with a 10-year history of chronic cough, dyspnea, weight loss and wheezing was referred to us for exacerbation of her symptoms in winter. She was a known case of anthracosis. Her previous bronchoscopy and sampling were inconclusive. Her recent computed tomography (CT) scan showed bilateral parenchymal infiltration, multiple lymph node calcifications and an intra-luminal calcified material in the left main bronchus. Bronchoscopy showed a floating foreign body in the left main bronchus and infiltration of the right and left main bronchi. Bronchial lavage showed plenty of acid fast bacilli and biopsy showed granulomatous reaction in favor of tuberculosis. In conclusion, we believe that broncholithiasis should be considered as a chronic complication of anthracosis.

A 49 year-old non smoker man from an Iranian rural region residing in Tehran, presented with chronic non-productive cough since 7 months ago. He worked in a dairy farm located in Tehran and had a 7-year history of contact with chemical agents. He had fever and night sweats since 3 months ago with episodes of myalgia and arthralgia and a 10 kg weight loss. He did not give any history of hemoptysis or dyspnea. During this period he was treated with multiple courses of antibiotics including ceftriaxone and azithromycin without any improvement. He was also under a regimen of clonazepam and amitriptyline for a major depressive disorder. On physical examination, his vital signs were stable with no respiratory distress. All physical findings were normal, except for an oral temperature of 38.2˚C and end inspiratory crackles in lower lobes of both lungs. Complete blood count revealed a PMN dominant leukocytosis. Blood biochemistry, liver function tests and urinalysis were normal. Erythrocyte sedimentation rate (ESR) for the first hour was 125mm. PPD test was nonreactive. Three consecutive sputum smears and cultures plus sputum polymerase chain reaction (PCR) were all negative for mycobacterium tuberculosis. Severe restrictive pattern was observed in pulmonary function test. Transthoracic echocardiography was reported to be normal. Chest x-ray (Figure 1) and thoracic spiral CT scan (Figure 2) were performed. Ground glass opacity and infiltration in lingula, right middle lobe and both lower lobes with mild cardiomegaly and small sized mediastinal adenopathy were revealed on CT scan.