Tanaffos Respiration Journal
Volume:10 Issue: 2, Spring 2011

Presentation of pandemic H1N1 influenza (H1N1) is widely evolving as it continues to involve different geographic locations and populations. This study was conducted to improve the precision of clinical diagnosis of H1N1 (2009) influenza infection in an outpatient setting. A prospective cross-sectional study was conducted among adult patients (age >15 years) with influenza-like illnesses (ILI) from November 2009 to February 2010. Clinical, laboratory and epidemiological findings in the first week of illness were collected using a standardized datasheet. Influenza testing was performed by real-time reverse- transcriptase polymerase chain reaction (rRT-PCR). Thirty nine (24%) patients were positive for H1N1 and 123 (76%) were negative for any subtype of influenza A virus. Whilst otalgia (14% vs. 0 p= 0.01) was more prevalent in non-influenza A cases, cough (90% vs. 72% p = 0.03) and shortness of breath (67% vs. 47% p = 0.02) were more often associated with H1N1-infection. Comparative analysis of co-existing conditions and demographic factors of patients revealed no other significant differences between the two groups. The clinical presentation of H1N1 (2009) infection is largely indistinguishable from other acute respiratory diseases. Although previous studies suggested significant differences in demographic and co-existing conditions of H1N1 infected patients, our study shows that as the pandemic spreads worldwide and affects the majority of the population, H1N1 diagnosis based on clinical presentation and demographic characteristics has become less practical and much more difficult in tertiary care centers.

Fluid balance affects outcome in critically ill patients. We studied the effect of fluid balance on oxygen exchange by assessing alveolar-arterial oxygen gradient (PA-a O2) in mechanically ventilated patients. Our primary objective was to evaluate the difference in PA-aO2 and the secondary goal was to evaluate the differences in age and mortality rate. This retrospective observational study was performed on patients who were admitted to medical and surgical ICUs of Sari Imam Hospital, Mazandaran University of Medical Sciences, from 2003 to 2009. Daily fluid balance was calculated by input minus output. Thirty patients with continuous positive fluid balance (PFB) and 30 subjects with continuous negative fluid balance (NFB) during 4 consecutive days were enrolled in this study. PA-a O2 was calculated in these two groups. The mean (±SD) age was 48.9±21.2 yrs. in PFB group (19 males and 11 females) and 37.1±15.7 yrs. in NFB group (25 males and 5 females) which showed a statistically significant difference in age between the two groups (p=0.017). The 24h, 48h, and 96h fluid balances were 1226cc±881, 1311cc±751, and 957cc±661 in PFB group and -1122cc±692, -920cc±394, and -1164cc±695 in NFB group, respectively. The mean differences (±SD) of PA-a O2 in 24h, 48h, and 96h versus the same value in the admission day were 11.3±39.2, 1.69±51.1, and -1.50±64 in PFB subjects and -21.8±60.8, -27.8±84.9, and -19.3±68.7 in NFB patients. The difference was statistically significant only in the first day of admission (p=0.015). However, no difference was detected in overall mean oxygen gradient during 96h among the two groups. Mortality rate was significantly higher in PFB patients (P<0.0001). Positive fluid balance had no significant effect on PA-a O2 but can be used as a predictor of mortality.

Identification of gene rearrangements and clonality analysis are important techniques for the diagnosis of malignant lymphoproliferative diseases. These methods have various sensitivities based on the type of primer used and method of determination of polymerase chain reaction (PCR) products. This study aimed at determining the clonality of B cell non-Hodgkin lymphoma in Iranian patients using PCR method and 2 primers of FR2 and FR3. Paraffin embedded blocks of 67 patients with B cell lymphoma and 19 cases with lymphoid hyperplasia of the lymph nodes who presented to NRITLD, Masih Daneshvari Hospital were retrospectively reviewed. After extracting the genomic DNA using phenol and chloroform, clonal analysis was performed using semi-nested PCR by using two primers: FR2 and FR3. PCR products were determined using 2 techniques of heteroduplex analysis, polyacrylamide gel and silver staining and the conventional method of agarose gel and ethidium bromide staining. Appearance of 1 or 2 bands in the desired location were considered as a sign of clonality. Monoclonal gene rearrangement was observed in 62 out of 67 patients (92.5%) as one or two discrete bands appeared within 60-120 base pairs (bp) and 200-300 bp range. Of the mentioned patients, 53 cases (79.1%) had FR2 and 51 (76.1%) had FR3 rearrangement. Heteroduplex analysis along with silver nitrate staining detected 3 out of the remaining 5 cases of lymphoma to be monoclonal. These cases had been reported negative by the conventional technique. In total, 65 out of 67 patients (97%) showed monoclonal gene rearrangement using both the abovementioned techniques. All hyperplasia cases were polyclonal by this method. Our study showed that evaluation and detection of clonality using PCR, FR2 and FR3 primers along with heteroduplex analysis is a rapid sensitive technique for the diagnosis of malignant lymphomas.

One of the undesirable effects of maternal nicotine exposure during pregnancy is pulmonary hypertension. Since nicotine binds to its receptors on pulmonary vessels the hypothesis of this research was the possible structural changes that nicotine may cause on newborn vessels. Twenty-four female BALB/c mice were mated and finding vaginal plug was assumed as day zero of pregnancy. Pregnant mice were divided into 2 experimental and 2 control groups. Experimental group 1 received 3 mg/kg nicotine intraperitoneally from day 5 of gestation until the last day of pregnancy. Experimental group 2 received the same amount of nicotine during the same gestational days as well as the first 2 weeks after birth (lactation). The control groups received the same volume of normal saline during the same periods. At the end of exposure times, all the newborns (experimental and control) were anesthetized, their lungs were removed and immunohistochemical studies were carried out for tracing collagen. Our findings indicated that collagen reaction in the bronchial basement membrane (BBM) and extracellular matrix (ECM) of the lung parenchyma in experimental groups increased significantly compared to the control groups but these changes were not observed in BM of lung vessels in the experimental groups. These data indicate that nicotine exposure during pregnancy does not cause a significant change in collagen type IV in BM of lung vessels. But this does not mean that other types of collagen fibers do not indicate change because the wall thickness of pulmonary vessels in experimental groups increased significantly compared to the control groups.

Primary immunodeficiency diseases (PIDs) are a genetically heterogeneous group of disorders that affect distinct components of the innate and adaptive immune system, such as neutrophils, macrophages, dendritic cells, complement proteins, natural killer cells, T and B lymphocytes. These disorders are rare, with an estimated prevalence of 1:10,000 live births. This study aimed at describing the clinical features, disease complications, treatment modalities and overall outcome of patients with Primary Immunodeficiency Diseases (PID) in Masih Daneshvari hospital during a 7-year period (2001-2008). This was a retrospective study based on the review of patients’ medical records. Clinical, laboratory, and epidemiological data including personal and family history were obtained by reviewing records of patients admitted to the Pediatric Pulmonary Ward of NRITLD, a referral center for tuberculosis and lung diseases. The diagnosis was made based on WHO criteria for primary immunodeficiency disorders. Data collected from 59 patients were evaluated and analyzed. There were 35 (59.3%) males and 24 (40.69%) females. The age of patients ranged from 6 months to 14.5 years and the mean age was 7.4 years. Positive family history was detected in 20 (33.9%) cases and parents of 36 patients (61.2%) were consanguineous. Twenty patients (33.9%) had a family history of PID. Phagocytic disorder (57.2%) was the most common form of PID, followed by antibody deficiency (33.7%) and T-cell or combined deficiency (8.2%). No case of complement deficiency was detected. In this group of under study patients, 2 cases expired as the result of respiratory failure due to drug resistant pneumonia (chronic granulomatous disease cases). Based on studied results, Phagocytic disorders (57.2%) were the most common disorders among our PID patients. This may be due to the large number of CGD patients referred with the pathologic finding of granuloma misdiagnosed with tuberculosis. Considering the high prevalence of PID in this study, cases with unusual, chronic, severe or recurrent infections should be evaluated for immunodeficiency disorders.

There are several occupations that can expose people to some air pollutants. Dental technicians are exposed to inorganic dust and chemical vapors when making dental prosthesis that can put them at risk for respiratory problems. This study was performed to assess respiratory dysfunction in a group of dental technicians. This was a cross-sectional study designed to ascertain the prevalence of respiratory disorders in dental laboratory technicians in Rasht, a city located in north of Iran. A Structured questionnaire was adapted according to the European Community Respiratory Health Survey questionnaire and used to elicit information regarding sociodemographic characteristics and medical status of the study participants. The ventilation status, protective measures and direct exposure to materials in the laboratories were directly observed by the observers and subjects underwent respiratory tests and chest x-ray. The mean age of dental technicians was 31.31 yrs (range 18-56 years) and 83% were males with a mean dental work experience of 9.04 years. In 54.8% of cases, the work environment did not have air conditioning system. The most common signs and symptoms were cough (38.1%) and wheezing (16.7%).There was a significant correlation between smoking and respiratory signs. Restrictive airway pattern and air trapping were two prevalent findings which were observed in 85.7% and 33.3% of the subjects. Cigarette smoking had a negative effect on FEV1, FEF25%-75%, and TLC causing a significant reduction in all three parameters (p<0.05). The most prevalent finding was interstitial opacity which was observed in 10 individuals (23.8%).This finding was not significantly associated with age, gender, cigarette smoking, or daily work hours. However, there was a significant statistical association between work experience and interstitial opacity. The prevalence of respiratory dysfunction and chest x-ray findings were high as in several similar studies. In order to reduce the hazards of respiratory disorders in risky occupations and provide dental workers with technical preventive measures, a more comprehensive study should be conducted throughout the country and further evaluations through biopsy and CT-scan need to be performed in suspicious cases when necessary.

Tuberculosis (TB) is among the major causes of illness and death worldwide, especially in Asia and Africa. On the other hand, tobacco use is the most important preventable and the second biggest cause of death throughout the world. Smoking is associated with recurrent tuberculosis and its related mortality. Also, it could affect clinical manifestations, bacteriological conversion and outcome of treatment. This study aimed to evaluate the pattern of tobacco smoking, history of previous quit attempts, and attitude towards quitting in tuberculosis patients. It was a cross-sectional study done amongst pulmonary TB patients presented to Masih Daneshvari Hospital. Two hundred patients entered the study as "First Come First Serve". Self-reported questionnaires were designed according to the standard questionnaires of smoking pattern. A total of 93.5% were males. The mean age was 39.8±1.73 yrs. Thirty-four percent of them were current smokers at the time of interview, 7.5% were occasional smokers and 28% of smoker patients had a history of at least one quit attempt. Considering the prevalence of smoking in TB patients, evaluation of tobacco smoking status in such patients and motivating them to quit smoking could be considered as important steps in their treatment process.

The main responsibility of an anesthesiologist is to safely maintain an open airway and preserve sufficient gas exchange in the lungs. This role becomes more significant when managing children especially those with difficult airways (DA). In such cases, a quick appropriate action can decrease the related mortality and morbidity. Laryngeal mask airway (LMA) is a device used in cases with difficult airways. Its placement is much more difficult in children especially those with DA. There is a greater risk of malpositioning and its insertion with routine techniques is sometimes impossible. In this article, we introduce a new method for replacement of LMA in difficult pediatric airways (DPA). In this before and after, pre and post design clinical trial, we evaluated 30 children with congenital anomalies and difficult airways who were candidates for elective eye surgery (short term). A written consent was obtained from the parents or the legal guardians of those who met the inclusion criteria. Inhalation anesthesia was induced by sevoflurane. The patients had assisted spontaneous respiration. No muscle relaxant was administered. LMA was inserted using the classic method in the anesthesia depth of BIS=35-40. After 2 unsuccessful attempts according to the criteria for adequate function of LMA, we tried placing the LMA using our innovated method after meeting the primary requirements and reaching the anesthesia depth of 35-40. In this method, the index finger of the left hand was placed on the tongue pushing it downwards (towards the floor of the mouth) when inserting the LMA. This way, we assisted LMA passing down the pharynx resulting in its adequate positioning. Criteria for adequate function of LMA in both classic and innovated insertion methods included monitoring of easy ventilation, no resistance during exhalation, adequate chest movement, no air leakage, optimal airway pressure, optimal lung compliance, level of oxygenation of arterial blood and level of CO2 at the end of exhalation. In case of presence of air leakage with bag pressure below 15 cm of water, lack of chest movement during inhalation, upper airway pressure over 20 cm of water, SPO2 lower than 90% and low compliance of the lung, LMA placement would be considered a failure. In such cases, LMA would be immediately extracted and the required depth of anesthesia would be reached using an oxygen mask and required inhalations. Complications occurring during the procedure and after LMA extraction would be recorded. Our understudy population included 30 children in the age range of 1.5 months to 10 yrs (11 girls and 19 boys) who had clear DA criteria due to syndromes and severe congenital anomalies and were candidates for elective eye surgery. Duration of the operation was 30 to 60 minutes. In all 30 cases, LMA placement with the classic method was not successful after 2 attempts by an expert. LMA was successfully inserted for all cases by the same person using the innovated method after meeting the required criteria (BIS=35-40). All ventilation indices were met and the operation was performed successfully with no complication. There is always a risk of unsuccessful LMA placement in difficult pediatric airways using the classic method of insertion. The innovated method recommends pushing down the tongue by the index finger of the left hand. Considering the hypersensitivity of children to hypoxia and risk of unsuccessful LMA placement by the classic method, the innovated placement method is advised in children suffering from anomalies associated with macroglossia.

Lung malignancy invading the left atrium is rarely seen. We present a patient with a fast growing symptomatic lung mass. Electrocardiogram showed persistent coving ST elevation with no biomarker change. Transthoracic echocardiography showed a large left atrial mass attached to the free walls and extended into its appendage. An apparent continuity with a large lung mass compressing left ventricular lateral wall was observed which was better evident in computed tomography of the chest.

We report a case of a 54-year old female who presented with chronic cough. Computerized tomography (CT) scan of the chest was not remarkable. She underwent empirical treatment for common causes of chronic cough for months to no avail, after which flexible bronchoscopy revealed right lower lobe endobronchial mucoepidermoid carcinoma. Surgical resection resulted in complete resolution of the cough.In patients with refractory cough who do not respond to conventional medical therapy, examination of endobronchial tree by bronchoscopy is strongly recommended.