Tanaffos Respiration Journal
Volume:23 Issue: 2, Spring 2024

There have been safety concerns regarding the COVID-19 vaccines because of their unprecedented speed of development. Therefore, systematic reviews are necessary to address these concerns and reduce public hesitancy regarding COVID-19 vaccines. This study aims to systematically review the reported adverse events related to viral vector COVID-19 vaccines.

We performed a systematic search in the databases of PubMed, Scopus, Web of Science, and Cochrane on September 15th, 2021. This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. The records underwent two-step title/abstract and full-text screenings, and the eligible records were included in the data extraction process. We used the Newcastle-Ottawa Scale (NOS) for the Bias Assessment of included articles.

The adenovirus vector-based COVID-19 vaccines, including the Janssen COVID-19 vaccine, the AstraZeneca COVID-19 vaccine, and the Sputnik V vaccine were included in this review. Among these vaccines, the AstraZeneca has presented enormous side effects with most being systemic and a few sporadic cases of life-threatening events such as thrombosis and capillary leak syndrome and even death in a few cases. Prominent systemic side effects of the adenovirus vaccines include fever, fatigue, malaise, arthralgia, myalgia, sweating, and dizziness. Erythema, swelling, tenderness, itching, and numbness at the injection site are the most common local reactions.

It appeared that the frequency of serious adverse events is negligible, and vaccination to prevent severe COVID-19 and mortality has greater benefits than adverse events in the general population.

Due to the rapid launch and development of vaccines (the most ideal protocol for countering COVID-19), monitoring of post-vaccination side effects is essential. This study aimed to assess symptoms and side effects of three types of COVID-19 vaccines (Sputnik, AstraZeneca, and Sinopharm) and the details of their relationship with demographic characteristics in Iran.

A cross-sectional and telephonic interview-based study was conducted from May 12 to July 11, 2021, among 420 university staff who received both doses of the COVID-19 vaccine. The association of vaccination behavior-related symptoms after the first and second doses with age, gender, vaccine type, blood type, underlying medical situation, and past infection and reinfection with SARS-CoV-2 was analyzed.

The majority of participants were men (58.7%), the median age was 41.30+11.208 years, and 18.6% were vaccinated with the Sputnik vaccine, 75.1% with Sinopharm, and 6.3% with AstraZeneca. In addition, 47.3% and 41.8% were symptomatic after first and second dose vaccination, respectively. The frequency of symptoms was higher in younger individuals, women, and AstraZeneca recipients (p = 0.001). The most frequently reported symptoms were fever, weakness, and muscular and injection site pain. These symptoms were more reported after the first dose than the second one. There was no significant connection between blood types, underlying medical situations, past infection and reinfection with SARS-CoV-2, and the prevalence of symptoms.

AstraZeneca, Sputnik, and Sinopharm COVID-19 vaccines were found to be safe and the lowest incidence of symptoms was seen in Sinopharm recipients.

During the last decade, more attention was paid to the tumor cell microenvironment, especially to tumor stroma-infiltrating lymphocytes (TILs). This study aimed to assess the prognostic impact of different TILs subpopulations and PD-L1 positive tumor cells in localized lung adenocarcinomas. We conducted a retrospective descriptive study, which included localized adenocarcinomas diagnosed in the department of pathology and resected in the Thoracic Surgery Department of the same hospital between 2015 and 2020. TILs were analyzed using the immunohistochemical method for Fox-P3, CD4, CD8, CD20, and CD3. Besides, the PD-L1 antibody was used to assess tumor cell expression. Intra-tumoral and stromal labeled lymphocytes were quantified by manual counting at high magnification (X400). Fox-P3+/CD8+, Fox-P3+/CD4+, FoxP3+/PD-L1+, and CD8+/CD4+ ratios were subsequently calculated. The prognostic value of TILs was assessed with respect to overall survival (OS) and recurrence free survival (ReFS). A total of 44 localized adenocarcinomas were included. In the univariate analysis, the prognostic factors influencing OS included gender, adenocarcinoma subtype, Tumor-Infiltrating Lymphocyte (TIL) score, TIL grade, PD-L1 expression, PD-L1 grade, tumor immunity in the microenvironment, and the expressions of various immune markers: CD3, CD4, CD8, CD20, and FoxP3. The analysis also considered the FoxP3 ratio, FIL score, and different ratios involving immune markers, such as CD8/CD4 ratio, FoxP3/CD8 ratio, FoxP3/CD4 ratio, and FoxP3/PD-L1 ratio. The prognostic factors influencing the ReFS consisted of gender, the adenocarcinoma subtype, TIL score, TIL grade, PD-L1, PD-L1 grade, TIM, CD8 expression, CD20 expression, FIL score, Fox-P3/CD8 ratio, Fox-P3/CD4 ratio, and Fox-P3/PD-L1 ratio. Multivariate analysis revealed no independent predictive factors of OS or ReFS. Despite the limitations of this study, the results highlighted that TILs may not represent an independent prognostic factor in localized adenocarcinomas and don’t play a major role in comparison to the tumor stage.

The physical basis of ventilator-induced lung injury has been explored extensively in the last decades. The three mechanisms named volutrauma (overdistension of alveoli), barotrauma (high airway pressure), and atelectrauma (cyclic opening and closing of alveoli) have been known as the main mechanisms of lung injury. Lowering tidal volume and applying positive end-expiratory pressure have been suggested to minimize these mechanisms. Besides, some researchers believe that elevated airflow-related shear stress on the epithelial cell layer could cause an inflammatory response.
In this study, a simplified 0-D model for air flow in human lungs has computed the airflow-related shear stress. The airway resistance, compliance, and inertance have been calculated using Womersley analysis and included in this model. Considering a constant flow, volume-controlled mechanical ventilation, the effect of ventilation parameters including tidal volume, respiratory rate, and inspiratory/expiratory ratio on the magnitude of shear stress has been investigated.
The results show that high tidal volume, high respiratory rate, and low inspiratory/expiratory ratio, increase the magnitude of wall shear stress but still in the safety range.
This result suggests that airflow-related shear stress is not the primary cause of mechanical damage. So far, it has been assumed that wall shear stress plays a critical role in ventilator-induced lung injury. This paper enhances our understanding of wall shear stress magnitude, indicating that the shear stress from airflow in mechanical ventilation is not high enough to inflict mechanical damage on pulmonary epithelial cells.

Asthma is one of the most common respiratory diseases. Hyssopus officinalis L. is a medicinal herb that has shown anti-asthmatic effects and has also been recommended in Persian Medicine literature for its treatment. In this study, the efficacy of hyssop in mild to moderate asthma was investigated considering the patients' phenotype (having productive/non-productive cough).

In a randomized triple-blind placebo-controlled trial, 60 mild-to-moderate asthmatic patients were randomized to receive either hyssop syrup (5 ml twice daily containing 6g Hyssopus officinalis L. extract) or plain sugar syrup (5 ml twice daily) for 4 weeks as an adjuvant to routine treatment. Outcome measures were the Asthma Control Test (ACT), pulmonary function tests, Expert Panel Report 3 (EPR3), and wheezing severity.

The patients with productive cough in the hyssop group showed significant improvement in forced expiratory volume in 1 second (FEV1), ACT (at the 4th week), peak expiratory flow (PEF), maximal expiratory flow rate 25-75 (MEF25-75%), and wheezing severity. However, those with dry cough got worse regarding these indices.

Hyssop syrup is effective for asthmatic patients with productive cough and a higher BMI, but it is not suitable for those experiencing a dry cough. It highlights the importance of syndrome differentiation in asthmatic patients and a posteriori subgrouping in data analysis. This approach enhances treatment accuracy and response rates while reducing adverse effects. Future trials are guaranteed to approve this categorization in asthma treatment.

To compare the efficacy of a high-flow nasal cannula (HFNC) versus conventional oxygen therapy (COT) in the treatment of patients admitted to the emergency department (ED) for acute respiratory failure (ARF).

In this prospective randomized clinical trial, 66 patients aged 18 years or older who presented with ARF to the ED were enrolled and assigned into two equal groups to receive either COT or HFNC for 60 minutes. The primary outcome was the intubation rates. The secondary outcomes were the effect of intervention on oxygenation, ICU admission rate, and effect on physiologic variables.

33 patients were treated in each group. The main causes of ARF were chronic obstructive pulmonary disease (COPD), pneumonia, and asthma. The need for intubation was higher in COT than in HFNC (42.5% vs 12.1%, P = 0.004). Patients with HFNC had a higher dyspnea improvement than those treated with COT (93.9% vs 63.7%, P = 0.002). They also showed greater improvement in oxygen saturation (increase in SpO2 was 8.3% vs. -0.5, difference 8.8% (6.8 to 10.9)), and in respiratory rate (decrease 3.0 beats/min vs 0.2 beats/min, differences 2.8(0.8 to 4.6)). The ICU admission was higher in the COT group (51.5 vs 15.2, P=0.002).

HFNC reduced the need for intubation and ICU admission in the patients presenting to the ED with ARF compared with COT. In addition, HFNC was associated with a greater reduction in RR and improvement in SpO2 compared with COT.

Safe airway management during anesthesia induction is a challenging issue. Airway-related morbidity can be prevented by carefully evaluating patients and formulating a difficult airway management strategy. The purpose of this study is to investigate and compare two indices, AASI, and HMDR, in predicting difficult laryngoscopic visualization.

Six hundred and twenty-two patients, who entered the operating room for any type of elective surgery and were candidates for general anesthesia, underwent AASI and HMDR measurements after filling out a questionnaire containing personal information, oral examinations, and history of illness or surgery before anesthesia prescription. The Cormack grade was recorded during laryngoscopy, and finally, the predictive value of the two methods was compared.

Based on analysis, AASI has a higher specificity than HDMR (87.5% vs. 76.1%) and the positive predictive value of AASI is 97%. Therefore, both HMDR and AASI are valid and significant indicators for predicting difficult laryngoscopy.

AASI has a better diagnostic profile than HMDR regarding sensitivity and positive predictive value, Additionally, AASI is more convenient to use because it is simpler and visually predictable, making it a reliable clinical predictor.

This study aimed to summarize the baseline and radiological characteristics of patients with COVID-19 and investigate the correlation between clinical outcomes and radiological findings in the first week after admission.

A single-center retrospective study was carried out on confirmed cases of COVID-19 based on RT-PCR and chest CT scan findings according to Iran’s National Guidelines for defining COVID-19 in patients admitted to Imam Hossein Hospital, Tehran, Iran. Baseline and chest CT scan characteristics of patients were investigated, and their correlation with the change in clinical outcome was reported.

72 patients (50%) with a mean age of 54.65±16.2 years were in two periods of time including the first day of diagnosis and 6.0±3.4 days later. Based on CT scan Severity Score (CTSS) changes (decrease/no change or increase) during the study, patients were divided into two groups of CTSS progression (n=47) and CTSS no-progression (n=25). Diabetes mellitus (20%) and hypertension (19.1%) were the most frequent comorbidities among the patients in the non-progression and progression groups, respectively. There was no significant difference in demographic features including age and gender, and comorbidities (P>0.05). On the first day of diagnosis, there was no significant difference in blood tests and radiological findings and the number of patients who managed out-patients or in-patients in both groups. However, on the second evaluation day, patients in the progression group had significantly higher CTSS in comparison with the non-progression group (13.11±4.7 vs. 9.48±4.2, P=0.003), and the clinical situation in 15 patients in progression changed from out-patient to in-patient (p=0.033).  Only chest CT imaging score was a potential parameter associated with the change in clinical progression (P=0.030, RR=10.18, 95, CI=1.25-89.72).

Increasing CTSS is a strong predictor of worsening clinical outcomes during hospitalization in COVID-19 patients.

The recent outbreak of Coronavirus 2019 (COVID-19) is a respiratory disorder caused by the Acute Respiratory Syndrome Coronavirus 2. At the start of the epidemic, early intubation was the optimal strategy for managing ARDS caused by COVID-19. Several non-invasive methods for respiratory support in patients with moderate to severe COVID-19 may reduce intubation, disease severity, ventilator use, and hospitalization in the intensive care unit (ICU). In this study, the characteristics of COVID-19 patients who failed NIV therapy were compared with those who had successful NIV. 
The present descriptive-analytical study was conducted at the COVID-19 center of KHORSHID University Hospital. Patients were aged > 18 years with confirmed COVID-19 and hospitalized in the ICU from the beginning of January to the end of March 2021. They had an oxygen level of < 88% despite receiving 15 L of oxygen with reserve masks and were undergoing non-invasive ventilation (NIV) treatment. Data collection included patients' demographic information, vital signs, and test results upon hospital admission, and assessed disease severity using APACHE, SAPS, and SOFA scores. Patients were categorized into responders (R) and non-responders (NR) to determine predictors of non-invasive ventilation (NIV) success, with follow-up based on device tolerance and changes in vital signs.
71 Individuals were candidates for NIV. Twenty patients were excluded from the study, and 51 patients were included in the study. Of these, 35 patients underwent NIV treatment failure (NR). On the other hand, 16 (31.4%) patients completely recovered after receiving NIV (R) and they were discharged from the ICU.
Serum Albumin and BMI levels of COVID-19 patients undergoing NIV therapy seem to affect their responses to treatment. Hence, it is recommended to evaluate the nutritional status of patients before the start of NIV.

Forecasting the longevity of patients' immune stability could be the most effective approach to preventing illnesses. This study investigates immunoglobulin M (IgM) serum longevity, immunoglobulin G (IgG), and corresponding risk factors in the first phase seropositive patients in Mazandaran, Iran.
This descriptive cross-sectional study aimed to assess IgM and IgG serum levels in a cohort of 184 seropositive patients during six months. The data analysis involved various statistical methods including descriptive statistics, the chi-square test, independent and paired t-tests, and single and multivariate logistic regression.
A total of 103 (56%) patients lacked the necessary antibodies, whereas 81 (44%) remained seropositive. According to the results of multivariable logistic regression, patients with a travel history, hospital admissions, and end-stage renal disease (ESRD) had 3.24 (P=0.04), 12.63 (P=0.018), and 9.79 (P=0.001) times higher chances of stable seropositivity, respectively. The average IgG and IgM serum levels fell by 4.5 and 3 units, respectively (P<0.001). In addition, serum levels of IgM and IgG increased by 12% and 12.5%, respectively, and dropped by 75.5% in both serums. There was no increase in either serum level for any of the patients.
The duration of immune serum stability in patients can significantly reduce disease mortality. The concurrent detection of IgM and IgG antibodies also assists in identifying the infectious stage.

During the COVID-19 pandemic, disease coding significantly influenced national and international strategies for prevention, treatment, and control. This study aimed to assess the factors influencing COVID-19 records' coding errors in teaching hospitals in South Khorasan province.
In 2022, researchers conducted a cross-sectional study in South Khorasan Province, Iran. Data was gathered using a self-developed questionnaire distributed among medical coders in all hospitals. Descriptive statistics were employed in the data analysis using SPSS version 19.
The study's results showed that non-observance of diagnostic principles by physicians (66 out of 92), a lack of specialized medical coding specialists (52 out of 92), and the use of ambiguous and non-standard abbreviations (51 out of 92) were the most significant factors affecting COVID-19 coding errors. Among the three main factors affecting COVID-19 records' coding errors, factors related to the medical coder (47.66 out of 92), factors related to healthcare providers (29.8 out of 92), and organizational and environmental factors (21.4 out of 92) were the most significant.
This study revealed that multiple factors contribute to coding errors in COVID-19 records, with the most critical being physicians' non-adherence to diagnostic principles, the shortage of medical coding specialists, the use of unclear and non-standard abbreviations, and the absence of COVID-19 coding continuing education. Therefore, we recommend conducting workshops on diagnosis and coding for medical coders, particularly emphasizing the precise coding of COVID-19 records.

Medication errors can lead to damage to patients with various disabilities or death. This study aims to identify factors affecting the incidence of medication error and its association with patient safety culture from the nurse’s perspective during the COVID-19 pandemic.

This cross-sectional study was conducted among 340 employed in the hospitals affiliated with Shiraz University of Medical Sciences in 2021. Data were collected by applying a questionnaire for medication error and the standard questionnaire of the Hospital Survey on Patient Safety Culture. Descriptive statistics, the independent t-test, ANOVA, and Pearson correlation were applied using SPSS software version 23.

The main reasons for medication errors were fatigue due to the workload (3.13±1.16 out of 5), method of supervision in the hospital units (3.06±0.98 out of 5), and massive pile-up of duties (3.00±1.19 out of 5). Other results indicated a significant negative association between factors affecting medication error and patient safety culture (r=-0.574, p=0.002). A significant correlation was observed among factors affecting medication error and patient safety culture with demographic determinants of age and years of working experience (p<0.05). Significant differences were also observed among the two main studied variables, the number of monthly work shifts, and the number of patients (p<0.05).

Applying strategies for the reduction of physical fatigue and mental exhaustion along with balancing work shifts and managing the accumulative duties and massive tasks can help decrease the rates of medication errors.

The halo sign and reverse halo sign are two computerized tomography scan views based on the placement of ground glass opacity. These two views have various differential diagnoses, but infections are known to be the most important differential diagnosis in both views. Lung adenocarcinoma, one of the deadliest tumors of both genders, can be included in the differential diagnosis. Nevertheless, we decided to report this case since both of these features were present in the same patient.

A 51-year-old man presented with gradual symptoms such as shortness of breath and myalgia, with a history of smoking and coronavirus disease 2019. In his computerized tomography scan, two views of the halo sign and the reverse halo sign were seen along with other lesions. In further investigations, due to his lack of recovery, a biopsy was prepared. Finally, with a definitive diagnosis of lung adenocarcinoma, we treated the patient appropriately.

When a patient presents with a halo sign and reverse halo sign on a computerized tomography scan and has a smoking history, it is necessary to take a biopsy of the observed lesions to rule out primary lung carcinoma.

WHAT IS YOUR DIAGNOSIS?An Iranian 26-year-old man was referred to our hospital with chief complaints of productive cough and hemoptysis. He presented with fever, cough, weight loss of 4 kg within the past month, and no history of other diseases. He also had a history of unprotected sexual contact and inhalational heroin abuse. On physical examination on the day of admission to our hospital, the patient was febrile (38.5 °C) with a pulse rate of 116 beats/min. Physical examination was unremarkable except for oropharyngeal candidiasis. The chest radiography (CXR) revealed a cavitary lesion in the left upper lobe (LUL) and parenchymal infiltration in the right upper lobe (RUL) (Figure 1A). The complete blood cell count results were normal except for a Hemoglobin count of 10.7 g/dl and a platelet count of 105,000/ml. The erythrocyte sedimentation rate was 97 mm/h. Alanine transaminase and Aspartate aminotransferase raised slightly to 54 mg/dl and 50 mg/dl (upper limit of normal: 40), respectively. The electrolyte profile, renal function test results, and urinalysis were normal. Therefore, we performed a lung computed tomography (CT) scan (Figure 1B). Sputum smears for acid-fast bacilli were negative three times. Empirical antibiotic therapy with Imipenem and Azithromycin was started. In complementary laboratory studies, test results were positive for Human Immunodeficiency virus (HIV) and Hepatitis C virus (enzyme-linked immunoassay and Polymerase Chain Reaction). Flow cytometry analysis of peripheral blood mononuclear cells demonstrated a CD4+ lymphocyte count of 13. No improvement in symptoms was obtained after empirical treatment. So, we repeated CXR and, after that, a lung CT scan which showed that pulmonary infiltration on the right side had worsened (Figure 1C and 1D), so bronchoscopy and bronchoalveolar lavage (BAL) were performed. BAL smear was negative for acid-fast bacilli, and pneumocystis jiroveci was not observed in special staining.  On the 10th day of admission, a non-tender, mildly erythematous mass lesion on the left forearm was found during the daily visit (Figure 2). Ultrasonography of the lesion showed an abscess without any sign of bone invasion. This cold abscess's pus culture yielded non-acid fast, gram-positive filamentous bacilli.