Tanaffos Respiration Journal
Volume:15 Issue: 3, Summer 2016

Active tuberculosis (TB) is one of the major opportunistic infections that may occur in solid organ transplant recipients. Diagnosis and treatment of latent and active TB are challenging in this population due to lack of randomized clinical trials. In this review, we discuss the clinical manifestations of TB, diagnosis of latent TB and treatment of both latent and active TB.

Lung biopsy through the airways by using a flexible bronchoscope (transbronchial lung biopsy: TBLB) is a suitable method for obtaining tissue specimens. This study aimed at evaluating the factors influencing TBLB results in order to increase the diagnostic power of this method.
This was a prospective double blind observational study. We had a total of 44 patients with pulmonary lesions who underwent biopsy and 4 specimens were obtained from each patient. A total of 176 specimens were obtained from all patients. Biopsy specimens were taken using cup and alligator forceps alternatively. Characteristics of the obtained specimens including size, floatation, alveolarity, and bleeding were thoroughly studied. After sending to the pathologist, specimens were divided into 2 groups of diagnostic and non-diagnostic specimens.
Of a total of 176 specimens, 37 (21%) were diagnostic and 139 (79%) were non-diagnostic. From 88 specimens obtained by the alligator forceps, 16 were diagnostic while from the same number of specimens taken by the cup forceps 21 had diagnostic value. However, this difference was not statistically significant (P>0.05). Of the small specimens (57 cases), 12 (21.1%) were diagnostic while among the 66 medium specimens, 12 (18.2%) and from the 53 large specimens, 13 (24.5%) were diagnostic. No statistically significant difference was detected in this respect (P>0.05). Among specimens floating on the surface of the liquid (48 cases), 6 (12.5%) had diagnostic value. Of the 12 specimens suspended in the liquid, 2 (16.7%) and among the 116 specimens precipitated at the bottom, 29 (25%) were diagnostic. These differences were not significant either (P>0.05). Of the 84 specimens with more than 20 alveoli, 31 (36.9%) were diagnostic. Among 26 specimens with less than 20 alveoli 5 (19.2%) were diagnostic. This correlation was statistically significant indicating that the higher the number of alveoli in the biopsy specimen, the greater the chance of being diagnostic.
This study failed to find a significant correlation between the diagnostic power of TBLB and type of forceps, sample size or floatation of the specimen in the liquid. However, number of alveoli present in the tissue specimens was significantly correlated with its diagnostic value. Increasing the number of specimens to four can increase the chance of diagnosis.

This study aimed to determine anthropometric indicators associated with dyspnea and spirometric parameters in patients with chronic obstructive pulmonary disease (COPD).
A cross-sectional and observational study was carried out on 88 patients with COPD, who were visited in an outpatient respiratory clinic of a university hospital during two months. Patient height, weight, body mass index (BMI), waist circumference (WC), mid-upper arm circumference (MUAC), triceps skinfold thickness (TSFT) and subscapular skinfold thickness (SST) were recorded. Also, data on lung function and dyspnea were collected. The association between anthropometric indices and other parameters was studied.
Pearson’s correlation coefficient showed that forced expiratory volume in one second (FEV1)% predicted was positively correlated with BMI (R=0.239, P There was a relationship between FEV1% predicted and some anthropometric indices such as BMI, MUAC and WC; also, we found an association between MUAC and dyspnea.

Bronchiolitis obliterans syndrome (BOS) is delayed allograft deterioration after lung transplant (LTX) that is clinically characterized by ≥ 20% decline from the baseline value of forced expiratory volume during the first second (FEV1). BOS is still a major obstacle limiting long-term survival post-LTX. The main aim of this study was to determine the predictors of BOS and death in Iranian LTX recipients.
This retrospective cohort study included 44 LTX recipients who survived ≥ 3 months post-LTX at the Masih Daneshvari Hospital, Tehran, Iran from 2000 to 2014. The outcome was time from lung transplantation to BOS and/or death (due to all causes except BOS). We used competing risks analysis to assess the effect of other factors on the cumulative incidence function of BOS and death. We applied a Fine and Gray model with Bayesian approach.
The recipients’ age (Mean ± SD) was 36.7 ± 14.5 yr. 11 (25%) recipients developed BOS as the first event within the first five years post-LTX and 13 (30%) died due to all causes except for BOS. Our results showed that CMV infection was associated with a significant increase in risk of developing BOS [hazard ratio (HR) 1.22 (95% credible set: (1.01, 3.2)] controlling for other variables. Bilateral transplantation [HR (95% credible set): 2.4(1.51, 4.05)] and CMV infection [HR (95% credible set): 2.02 (1.67, 2.55)] were predictors of the mortality risk.
CMV infection was a predictor of BOS risk in the studied patients. Moreover, bilateral transplantation and CMV infection were significant predictors of mortality in the present sample. Multi-center studies with larger sample sizes are required to better study the other risk factors, and the pathophysiologic mechanisms of BOS.

Mutations in pncA and gyrA genes cause pyrazinamide (PZA) and fluroquinolone resistance in Mycobacterium tuberculosis (MTB). In the present study, structures of pyrazinamidase (PZase) and DNA gyrase proteins were studied in resistant and susceptible clinical isolates of MTB.
Sixty clinical isolates of MTB were used in this study. Polymerase chain reaction (PCR) amplification of pncA and gyrA genes was accomplished on purified DNA. Sequence of the fragments was determined by an Applied BiosystemsTM apparatus. Bioinformatic analysis was performed by online software and three-dimensional (3D) structures of proteins was predicted using Molegro Virtual Docker (MVD) Modeler software.
Amplified 744 and 194 bp fragments of pncA and gyrA genes, respectively were yielded suitable sequence results. Predicted 3D structures of proteins showed some differences between wild-type and mutant structures. Mutation in amino acid No.31 (T92C) caused an increase in distance from metal ion position to enzyme active site, but it was considered as a polymorphism. Docking results by MVD revealed a relationship in quinolone resistance-determining regions (QRDR) amino acids in interaction with antibiotic. T92C mutation in PZase from non-polar aliphatic amino acid Ile (ATC) to polar aliphatic amino acid threonine (ACC) was a polymorphism.
Structural changes in two important proteins related to drug resistance were proven in clinical isolates of MTB.

Surgical site infections (SSIs) are common complications following surgeries and increase mortality,morbidity and healthcare costs. The use of antimicrobial prophylaxis is an effective measure to prevent development of SSIs. This study aimed to evaluate the current use of prophylactic antibiotics in thoracic surgeries in Iran.
A descriptive study was conducted among thoracic surgeons in order to assess their knowledge,attitude and practice (KAP) about surgical antibiotic prophylaxis (SAP). A four-section multiple-choice questionnaire was designed and hand-delivered to registered thoracic surgeons. The surgeons answers were considered correct when they were in accordance to the American Society of Health-System Pharmacist (ASHP) guidelines.
Seventy thoracic surgeons were requested to participate in this study and their response rate was 71.4%. Thirty-five (70%) surgeons had good knowledge about appropriate SAP. However,less than half of the respondents were aware of appropriate SAP in case of Ig E-mediated reaction to penicillin and risk of Gram-negative infections. The surgeon’s attitude score about the need for local and national guidelines for SAP was 78% and 90%,respectively. Accordance of the physician’s practice with ASHP guidelines regarding timing of the first dosage of SAP was acceptable while correct administration of an intraoperative dose was 40% in agreement with the guideline.
Although thoracic surgeons had a good attitude towards antibiotic prophylaxis guidelines,their knowledge and practice should be improved for proper administration of SAP.

The clinical diagnosis of chronic obstructive pulmonary disease (COPD) should be considered in any patient who has dyspnea, chronic cough or sputum production, and diagnosis should be confirmed by performing spirometry in presence of airflow limitation. The aim of this study was to assess the validity of a questionnaire used to detect COPD based on spirometry findings.
The validity of a questionnaire for COPD diagnosis was examined using spirometry based on both Global Initiative for Chronic Obstructive Lung Disease (GOLD) and American Thoracic Society/European Respiratory Society (ATS/ERS) criteria for patients 35 years old and older. In total, 350 questionnaires were completed. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio and negative likelihood ratio were calculated to determine the accuracy of the questionnaire.
The sensitivity of the questionnaire in detection of airflow limitation was 8.3% and 6.7% by the GOLD and the ATS/ERS criteria, respectively; whereas, specificity was 96% by both criteria.
The high specificity of the questionnaire indicates that the questionnaire is more capable to identify people who do not have airflow limitation; whereas, the low sensitivity of the questionnaire could underestimate the actual prevalence of COPD in the general population.

Borago officinalis and its derivatives are used in folk medicine to treat asthma because of its special effect on allergic disorders. It suppresses the tumor necrosis factor-alpha (TNF-alpha) and delivers gamma-linolenic acid. The objective of this clinical trial was to determine the effect of Borago officinalis on clinical and physiological findings in moderate persistent asthma.
This prospective, randomized, double blind, placebo-controlled, clinical trial was conducted on patients aged 15-90 years with moderate asthma and forced expiratory volume in one second (FEV1) of 60-79% of predicted who presented to a sub-specialty clinic of pulmonary medicine. We randomly allocated subjects to receive either Borago extract (5 mL three times a day) or a matched placebo for one month. The primary outcome was the asthma control test (ACT) score and fractional exhaled nitric oxide (FENO) test. Secondary outcomes included clinical findings, spirometry, and sputum cytology including inflammatory cells.
Thirty-eight subjects with a mean age of 46.8±15.3 years and mean duration of asthma of 71±103 months were enrolled in our study. Cough, dyspnea, wheezing, nocturnal symptoms, and airway hyper-responsiveness reduced significantly in the Borago group after the treatment and ACT scores improved significantly (10.8±5.26 before and 15.4±5.12 after the trial). Flare up of asthma and emergency department visits in the Borago group also decreased significantly (3.6±2.33 to 2±1.86 flare ups per month and 0.62±0.9 to 0.05±0.23 for emergency department visits per month). Physiological parameters including spirometry, FENO, and sputum cytology including eosinophil and neutrophil did not change significantly.
Borago improved the clinical findings of asthma, but it was not able to suppress the inflammation involved in asthma.

Myasthenia gravis (MG) is an autoimmune disease affecting patients’ quality of life and necessitating long-term medical therapy. The efficacy of thymectomy for treatment of MG has been well established. Although several techniques have been used for thymectomy, there has been controversy over the best method with highest rate of improvement. Herein, we discuss our seven years of clinical experience with thoracoscopic thymectomy for MG.
We evaluated all patients who were operated on with preoperative diagnosis of non-thymomatous MG from 2007 to 2013 in Masih Daneshvari Hospital (Tehran, Iran). All patients underwent thoracoscopic thymectomy, and rates of remission and cumulative improvement were compared to those reported by other studies.
Thoracoscopic thymectomy was performed in 34 patients with MG. The rate of complete remission and cumulative improvement at the end of the third year was 44.1% and 85.3%, respectively. Patients who were operated early after the diagnosis showed higher improvement rate, although it was not statistically significant (P=0.065).
Thoracoscopic thymectomy is a safe procedure for treatment of MG with comparable results to other techniques. Thymectomy soon after the diagnosis may be associated with higher improvement rate.

Concurrent use of tobacco products such as cigarettes and water pipes may be associated with increased risk of nicotine dependence and smoking-related complications. Accurate statistics are not available regarding the prevalence of water pipe use or concurrent use of cigarettes and water pipe in the Iranian population. Thus, this study sought to assess the prevalence of concurrent use of cigarettes and water pipes and their related factors in Iran.
This cross-sectional study was conducted on Tehran residents over 15 years of age, who were selected via cluster, multi-stage randomized sampling, from different geographical districts of Tehran between November and December 2014. The data were collected using the water pipe section of the Global Adult Tobacco Survey (GATS) questionnaire.
A total of 1,830 individuals participated in this study, 243 (13.3%) of which exclusively used water pipes, 76 (4.2%) used both cigarettes and water pipes, and 120 (6.6%) exclusive smoked cigarettes. Of those who used both cigarettes and water pipes, 86.8% were men and 13.2% were women (P The prevalence of concurrent use of cigarettes and water pipes and that of exclusive water pipe use were 4.2% and 13.3%, respectively. The prevalence of exclusive cigarette smoking was 6.1%. Those who smoked both cigarettes and water pipes had a higher mean age than those who exclusively used water pipes and they were mostly men. Among those who used cigarettes and water pipes, the mean age at which they began using water pipes was lower than the mean age at which they began smoking cigarettes. In other words, dual smokers started water pipe smoking sooner than cigarette smoking. Future studies with different methodologies are required to further scrutinize the relationship between water pipe and cigarette smoking. Smoking cessation programs must specifically target dual smokers.

Pregnancy is strongly discouraged in patients with pulmonary arterial hypertension (PAH). Herein, we report a successful delivery in a woman with PAH using a multidisciplinary approach. A 30-year-old pregnant woman with PAH was referred to us with a chief complaint of dyspnea. She was advised to terminate her pregnancy but she refused to do so despite several recommendations by healthcare professionals. She was scheduled for treatment with iloprost (brand name: Ilomedin) and heparin infusions for 3-4 days at 20-day intervals. She spent her last month of pregnancy in a hospital under close observation and received iloprost infusion. She underwent a successful cesarean section under general anesthesia at week 36 of gestation. Iloprost administration was continued for one week after delivery and was changed to bosentan after that. Meanwhile, heparin infusion was substituted by warfarin. However, treatment with bosentan led to a temporary interruption in breastfeeding. A few days later, she presented with severe dyspnea and pulmonary artery pressure of 110 mmHg. Treatment was restarted with iloprost, followed by stabilization with bosentan. A successful delivery was achieved in this situation by meticulous observation and aggressive treatment targeting PAH, along with long-term hospital stay and multidisciplinary management. Severe PAH is regarded as a contraindication to pregnancy. While physicians strongly recommend termination of pregnancy in such patients, some of them might refuse and insist on delivery of the baby. Similar pregnant cases with potential delivery are recommended to be evaluated for effective management of this condition. Key words: Pulmonary artery hypertension, Pregnancy, Termination