Tanaffos Respiration Journal
Volume:3 Issue: 4, Autumn 2004

The variability of the efficacy of M. bovis strain BCG used as a vaccine, and the controversial success of M.vaccae as an immunotherapeutic agent, lead the TB community to distrust these means to confront the resurgent TB problem. In addition, it is widely assumed that humoral antibodies against TB play only a minor role during mycobacterial infections. To shed some light on the reason for the observed failure of these immunological reagents, we analyzed the humoral immune response against the whole cells and the lysed cells of mycobacterial species M. tuberculosis, M.avium, M.paratuberculosis, M.vaccae and M.phlei, with antibodies raised against a pathogenic TB strain, against avirulent TB strain H37Ra, against A60 of BCG strain Pasteur GL-2 and against BCG strain Copenhagen. The reactivity of the thermostable macromolecular antigens (TMA) of BCG, M. paratuberculosis, M. phlei and M. vaccae, and of LAM extracted from BCG strain Pasteur GL-2 were also analyzed with these antibodies.The cellular immune activity of M. vaccae versus M. bovis strain BCG Pasteur GL-2 was analyzed by their capacity to induce an experimental arthritic syndrome.Results and Our results were that: 1- the serological response obtained by whole cells and lysed cells of M. vaccae appeared most closely related to M. tuberculosis while that obtained by the cells and lysed cells of M. phlei was the most different. However, the antibodies directed against the antigen 60 complex of BCG strain Pasteur GL-2 did not react immunologically very strongly with the lysed cells and the TMA of M.vaccae, 2- the antibodies against pathogenic TB cells, BCG sonicate strain Copenhagen and A60 from BCG Pasteur GL-2 recognized well whole cells and lysed cells of the BCG strains Copenhagen and Pasteur GL-2 but reacted poorly with the whole cells and lysed cells of a pathogenic TB strain and very poorly with the whole cells and lysed cells of BCG strain Aventis-Pasteur currently used as a vaccine (Monovax), 3- the LAM extracted from BCG strain Pasteur GL-2 was poorly recognized by monoclonal antibody CS-40 directed against the LAM of Virulent TB strain Erdman but was recognized by monoclonal CS-35 antibody, that recognizes all LAMs. This LAM was recognized with the same efficacy by the four anti-mycobacterial antibodies used, including antibodies against the A 60 complex of BCG, 4- the cell lysate and the TMA of M. vaccae did not stimulate as effectively the cellular immunity in vivo as did BCG extracts, as shown by their failure to induce an experimental arthritic syndrome under conditions that allowed its induction by the cell lysate and antigen 60 (TMA) of BCG.

We evaluated the association of active pulmonary tuberculosis with level of serum adenosine deaminase in order to have an acceptable rapid test to help the clinicians in the diagnosis of active pulmonary tuberculosis. We measured serum total adenosine deaminase level in three groups:1- Cases of active pulmonary tuberculosis that were confirmed by positive sputum smears for acid-fast bacilli in association with compatible clinical and radiological findings.2- Cases of other infectious diseases including brucellosis, endocarditis, salmonellosis, and meningitis confirmed by clinical findings and related laboratory tests.3- Healthy controls.Serum adenosine deaminase levels were measured before starting the treatment. Data analysis was performed by Chi-Square; ANOVA and LSD tests. The significant level was evaluated for p- value of less than 0.05. We evaluated 51 cases (21 females and 30 males aged 47.7±19 years) of active pulmonary tuberculosis, 11 cases (6 females and 5 males aged 44.7±21 years) of other infectious diseases and 50 cases (14 females and 36 males aged 48.4±11 years) of healthy individuals. Mean serum adenosine deaminase level in pulmonary tuberculosis (42.4±21.5 IU/ml) and other infectious diseases (38.3±23.4 IU/ml) was significantly more than controls (26.6± 8.2 IU/ml), (P<0.0001 and p<0.03 respectively), but the difference between the pulmonary tuberculosis and other infectious diseases was not statistically significant. There was no significant difference in age and gender between the above mentioned groups. We conclude that serum adenosine deaminase level increases in infectious diseases but it cannot differentiate pulmonary tuberculosis from other infectious diseases. (Tanaffos

The cause of pleural effusion in some patients can not be found even after biochemical, bacteriologic and cytological examinations of the pleural fluid and closed needle biopsy of the pleura. In this group of patients the next diagnostic step would be an open pleural biopsy through a limited thoracotomy or video-assisted thoracoscopic surgery (VATS), the latter procedure has replaced the former in many centers due to its advantages. In order to evaluate these advantages, 59 patients with undiagnosed pleural effusion were operated on through either limited thoracotomy or thoracoscopy form April 1998 to September 2000, in a prospective clinical trial. There were 40 males and 19 females in the age range of 10 to 89 yrs. There was no significant statistical difference between the two groups in terms of sex and age. There was no statistical difference between the two groups in terms of diagnostic accuracy, postoperative pain, hospitalization, morbidity and mortality. Based on these results and minimal scar, VATS is a safe diagnostic procedure in this group of patients replacing limited thoracotomy.)

In periodical occupational examination, for detection of pulmonary involvement, chest x-ray with ILO classification is used. This protocol is carried out on asbestos workers as well. However, chest x- ray is not valuable for early detection of asbestos related pulmonary changes.This study evaluated HRCT vs. chest x- ray in early detection of asbestos related pulmonary changes. This study was performed in November 2002 among "Hajat Chrysotile Asbestos Factory" and mine workers located in Nehbandan-Birjand, Khorasan province. A total of 49 asbestos mine workers with minimal respiratory symptoms were chosen. The level of asbestos in different areas of the factory and mine was measured. All workers were interviewed and underwent clinical examination, chest x-ray and HRCT. The mean value of asbestos in the respiratory field of asbestos exposed workers was about 80 times over the standard limits (39.75 f/ml; TLV= 0.5 f/ml). On chest x-ray based on ILO classification, 3 individuals (6.1%) showed reticulonodular involvement. The most common intensity of involvement was generally I/I in bases of the lungs. HRCT findings demonstrated pulmonary parenchymal involvement in 32 cases (65.3%). In 29 cases, there was no abnormality in chest x-Ray, while it was present in HRCT. In 17 cases both tests were negative. There was no positive chest x-ray in HRCT negative cases. Sensitivity of chest x-ray was 9.5% and specificity was 100%. According to sensitivity, use of chest x-ray as a diagnostic test for evaluation of asbestos related pulmonary diseases does not have enough value for detection of patients. Therefore, in the evaluation of occupational disorders and law suits (in those cases with the most simple sign and symptoms), HRCT should be performed.

Hydatid disease is the most common serious infection in human beings caused by cestods and Iran is one of the endemic regions of this infection. This research has been performed to evaluate and analyze the cyst location, its diagnosis and treatment This descriptive study was performed on the patients suffering from hydatid infection who were admitted in the pediatric department of Massih Daneshvari Hospital from March 1996 to April 2004. Data in regard to age, sex, clinical signs and symptoms, radiographic findings (location and number of cysts) and type of treatment (medical or surgical) were collected and analyzed statistically. A total of 11 patients suffering from hydatid cyst were evaluated in this study. Among these, 10 were male and 1 was female. Age range of patients was between 0 to 16 years of age and the mean age was 13 years. The results of this study show that pulmonary hydatid cyst in children is more common in boys.Cough (100%), sputum (100%), and hemoptysis (54.5%) were the most common symptoms. Chest x-ray and lung CT scan were obtained in all patients. CT scan diagnosed hydatid disease in 100% of the patients. Common locations of the cyst were in the lower lobes of both lungs in 81% of the patients while in 54% it was in the lower lobe of the left lung. In 2 patients we found hydatid cyst in both lung and liver. Surgical treatment was performed in all 100% of the patients. Among these, one patient underwent pulmonary lobectomy while in the remaining 10, surgical approach with evacuation of the cyst was performed. Hydatid disease is hyperendemic in Iran, and usually patients do not seek medical advice on time. It causes high mortality in patients even with proper treatment along with high costs of management. Therefore, it is necessary for the authorities and researchers to pay more attention in this regard. In this survey, CT scan was the best and the most definitive method of diagnosis and surgical treatment along with evacuation of the cyst was the selective method of treatment in 90% of the patients in this study.

Pulmonary embolism is one of the most common preventable causes of death in hospitalized patients and its related mortality and morbidity rate can be reduced considerably by proper treatment. It seems that there are some problems in treatment of acute pulmonary embolism in most health care centers.In this study, treatment of pulmonary embolism was evaluated in Tehran Imam Khomeini Hospital and compared with the standard therapy. All records of patients hospitalized with the diagnosis of acute pulmonary embolism during four years (1998 to 2002) were examined thoroughly.Major points under the study are: Treatment with heparin regarding the dosage, time of performing Partial Thromboplastin Time (PTT) test during the treatment in order to determine the drug efficacy, modifying the drug dosage according to PTT results and prescribing oral anticoagulants. Fifty four patients with mean age of 51.3 years entered the study. Bolus dose of heparin was administered to 16 patients (29.6%). In regard to later infusion rates of heparin, only in 2 patients the prescribed dosage (3.7%) was in accord with one of the standard protocols and in the remaining, drug dosage was less than the recommended rate.Therefore, the optimal therapeutic range of heparin according to PTT in the first 24 hours of treatment was achieved only in 12 cases.(22.2%)PTT was checked every 12 hours in one case and every 24 hours in 53 cases.The mean treatment period with heparin was 9.9± 4.6 days.The mean time of starting warfarin was 2.8± 2.3 days after heparin therapy and only 53.1% of the patients had International Normalized Ratio (INR) between 2 to 3 in two consecutive days at the time of discharge. Results of this study indicate that physicians usually tend to use insufficient doses of heparin and delay in starting warfarin. Furthermore, evaluation of the therapeutic effects was not performed in any patient by repeated PTT test specially in the first 24 hours of treatment.According to the results of various studies this type of therapy leads to increased rate of relapse, mortality and morbidity due to pulmonary embolism.

It is believed that H1 histamine receptor blocker does not have any beneficial effect on treatment of asthma, but combination of H1 and H2 receptor antagonists has a good effect on chronic resistant urticaria. Since the pathogenesis of asthma and urticaria are similar, we expected that this combination might have some benefits in treatment of asthma. In this study, we selected 66 patients with known diagnosis of asthma in acute exacerbation of their disease. The patients did not have any history of smoking, GERD, postnasal discharge and rhinorrhea, but experienced symptoms such as cough, dyspnea, and wheezing. All patients underwent spirometry (Spirosift 3000 Fukuda Denshi), and those who had obstructive pattern and improved FEV1 more than 20% after using bronchodilator were randomly entered either the case or control groups after signing the consent. Spirometry parameters were VC, FVC, FEV1, FEV1/FVC, PEF, FEF 25-75%, MEF25%, and MEF 50%.Phase 1: Case group treated with 0.5 mg/kg prednisolone and salbutamol orally plus terfenadine (bid) and Ranitidine (tid), for one week.Phase 2: Case group treated with salbutamol and beclomethasone spray with antihistamines as mentioned, for two weeks.Phase 3: Same as phase two for one month. Spirometry was done at the end of each phase.In control group since exclusion of corticosteroid and bronchodilator from treatment was dangerous, management was similar to the case group. The only exception was the omission of antihistamines.Statistical analysis: Chi-square was used for interpretation of qualitative variables. F statistics and Kruskal Wallis tests as well as paired t- test were used for comparison of changes in spirometry findings. 66 patients finished first and second phases and 24 patients went through the third phase. M/F ratio was 2/3, median age was 33 years in both groups (range10-70 yrs.). Comparison of symptoms between case and control groups showed that in study group during second phase, cough improved more than control group. Otherwise, there were no significant differences in symptoms and signs of the two groups. During all three phases, spirometry measurement showed no significant difference between study and control group, except for MEF25% that improved in study group more than control group in the second phase. Corticosteroids and b-2 agonists are very potent and effective drugs in treatment of asthma. Addition of H1 and H2 histamine receptor antagonists to standard therapy of asthma has minimal effect but in case of troublesome cough that is not relieved with that treatment, addition of antihistamines may be beneficial.

“Anesthesia Preoperative Evaluation Clinic” (A. P. E. C) is a center for pre-operative evaluation and preparation of the patients. The aim of this clinic is to obtain the essential data and history of the patient، optimize her/his condition in case of any co-existing disease before the operation and select the best method of anesthesia for the day of surgery. In an interventional quasi experimental study، pre and post operative para-clinical procedures which have been performed for patients having elective surgery were evaluated before and after establishing the APEC (1998 and 2001) in Labbafinejad Medical Center. After obtaining the demographic data including age، sex، ASA class and the type of surgery، two-hundred patients were placed in two groups. Information about the para-clinical results and requested medical consultation were recorded from the patients'' files. All costs and expenses were recorded for both two groups. After obtaining the data including the percentage of para-clinical procedure، chest x-ray، ECG، ASA class، type of surgery and postponed operations before and after establishing the APEC، they were compared by chi-square test. Bed-day occupying factors and costs in both groups were compared by t-student test. There were no significant differences between the 2 groups in terms of sex، ASA class and type of surgery. The number of admitted patients'' in the year 1998 was about three times more than the year 2001 (2. 11 days versus 0. 55 day) (p=0. 000) Chest x-ray was ordered for 18 %of the patients in the year 1998 group، whereas it decreased to about 0% (P=0. 000) for the year 2001 group. The number of ordered medical laboratory exams in group 2 (2001) was significantly less than group 1 (1998). Laboratory investigations were as follows: BUN (P=0. 016)، FBS (P=0. 000)، CBC (P=0. 004)، ESR (P=0. 006)، creatinine (P=0. 000)، urine analysis (P= 0. 000)، urine culture (P= 0. 000)، cholesterol (P=0. 000)، triglyceride (P=0. 000). Medical consultations in group 2 were less than group 1 (chi-square=154. 7، P=0. 000). Comparison of the peri-operative costs in all aspects showed a decrease after establishing the anesthesia clinic (P<0. 000). Number of the operations cancelled by anesthesiologists had been decreased to 0 in group 2. Regarding our findings، establishment of the anesthesia clinic is essential and cost-effective. The study showed that anesthesia clinic prevents extra expenses and time consuming and unnecessary paraclinical procedures which will be ordered only in necessary and consulted cases. Date of operation will be defined after optimizing the patient''s conditions to prevent unnecessary admission of patients، bed-occupying rate and postponed surgeries. It will save the precious time of physicians and hospital personnel and reduce the mortality and morbidity rate)

True pulmonary artery aneurysm secondary to disintegration of its walls is extremely rare and may be mistaken with lung tumor. Sometimes it may be discovered during thoracotomy.We present a 71- year old man with exertional dyspnea, cough and left sided chest wall pain who admitted to our hospital in April 1999. Conventional imaging suggested a left parahilar mass. Bronchoscopy was normal. Due to suspected lung malignancy, the patient became candidate for lobectomy.A huge pulmonary aneurysm was discovered at the time of thoracotomy. Since the patient could not tolerate pneumonectomy, a mersilene mesh was wrapped around the aneurysm and supported by it. He was followed up by obtaining chest x-ray, every 3 months in the first year and then every 6 months till now. There was no change in the size of the aneurysm and general condition of the patient is good.