Tanaffos Respiration Journal
Volume:2 Issue: 4, Autumn 2003

Patients with severe chronic obstructive pulmonary disease (COPD) have a poor quality of life and limited life expectancy, frequently resulting in depression that enhances their symptoms. This depressive state might need medical intervention; however, the safety of antidepressant drugs in these patients with poor respiratory function is not clear. Thirty-four subjects with concomitant COPD and depression as well as 34 controls with COPD without depression were enrolled in a single blind controlled study. Nortriptyline was prescribed to the first group and placebo to the second. Spirometric and gas analysis findings were compared before and after a three-month course of trial. Pulmonary function tests and gas analysis recordings did not show any deterioration after nortriptyline administration. Two deaths occurred during the study period, one in study group due to respiratory infection and the second in control group because of Pulmonary Thromboembolism (PTE). Nortriptyline is a safe medication to be used in COPD patients when indicated. (Tanaffos 2003; 2(8): 41-48)

The aim of our research was to study the characteristics of anthracotic bronchitis in patients undergoing bronchoscopy in Massih Daneshvari Hospital. All patients that showed anthracotic changes, edema, and/or bronchial stricture on bronchoscopy were studied and included. Bronchoalveolar lavage (BAL) was obtained from all of the patients and sent for BK, smear, culture, and cytological evaluations. Also, bronchial biopsy was obtained from some of the cases. A questionnaire having information such as personal data, place of residence, occupation, history of smoking, history of baking bread in traditional furnaces, and past history of TB was filled out for each patient. Meanwhile anthracotic sites that were observed in bronchoscopy were marked in specially designed tables. Out of 290 patients that had undergone bronchoscopy in a 4-month period during the year 2001-2002 in Massih Daneshvari hospital, 47 suffered from anthracotic bronchitis; 51.1% of the patients were male; 73.3% lived in the urban, and the remaining cases resided in rural areas; 10.6% had history of smoking and 29.3% baked bread in traditional furnaces. The most common symptom and sign were cough and rale, and the most frequent site involved was right lower lobe. Based on bacteriology and/or pathology, 27.7% of the patients had tuberculosis. The most common radiological finding was the increase of bronchovascular markings. - Anthracotic bronchitis is a very common disease in Iran. - In any middle or old-aged patient that has increased bronchvascular marking, collapse, atelectasis along with calcified mediastinal lymph nodes, anthracotic bronchitis should be considered in the list of differential diagnosis. - Any patient having bronchoscopic findings in favour of anthracotic bronchitis should undergo all the necessary evaluations for TB. (Tanaffos 2003; 2(8): 7-11)

Lining is made up of different materials, the most important and dangerous one being Asbestos. With the increasing knowledge and awareness of lining workers (men who repair brake linings) in regard to asbestos and its associated dangers, this concept is induced in their mind that they might be affected by asbestos-related lung diseases. The aim of this study was to determine the prevalence of asbestos-related pulmonary diseases among the lining workers and lining makers of Isfahan. In a cross-sectional study, 47 workers (18 from Gort lining factory, and 29 from lining workshops of Isfahan) were evaluated. They underwent history taking, clinical examination, chest x-ray (CXR), spirometry, CT-scan (HRCT), bronchoscopy, and bronchoalveolar lavage (BAL) examinations. Since there were no reports measuring the number of asbestos fibers in the air of the working places (factory and workshops), the mean number of asbestos fibers in these areas was calculated. A total of 47 male workers were studied. The age range was 35-75 years, mean ± SD=47.96±10.33, and 95% CI=45.01, 50.91. Also, they had an occupational history of 20-69 years, mean ± SD=29.57±8, and 95% CI=27.28, 31.86. The frequency of asbestos related pulmonary diseases (pulmonary fibrosis, pulmonary plaque, peribronchial thickening) was 21.28% (17.03% among smokers) with relative frequencies of smoking 64%, cough 31.92%, sputum 48.94%, dyspnea 72.34%, and wheezing 19.15%. The frequencies of abnormal CXR, spirometry, and HRCT were 27.6%, 23.5% and 19.2% respectively. The number of asbestos fibers in the air of the working place was mean±SD=0.36±0.1 fbr/cc (p value<0.05, t=3.26). Exposure to asbestos without considering the safety measures and principles of occupational health and security results in a number of asbestos-related lung diseases among the lining workers and lining makers. It is notable that smoking augmentates the harmful effects of asbestos: the fact which has been confirmed by clinical and para-clinical examinations of this research. Due to short mean duration of occupational history, asbestos-related malignant pulmonary disease was not detected. As a conclusion, in addition to abstaining from smoking, obeying the health-security measures present at work and finding a suitable replacement for asbestosis in lining industries as well as follow-up and regular screening of the workers are also recommended. (Tanaffos 2003; 2(8): 13-22)

Smoking is known as the major cause of chronic obstructive pulmonary disease (COPD). In COPD, most of pulmonary function tests (PFTs) specially those indicating the diameter of airways are reduced. There are reports that bronchodilator drugs have no or a very little effect on PFT of COPD patients. Therefore, in this study PFTs of smokers were compared with those of nonsmokers, and the effect of bronchodilator inhaler (salbutamol) on PFTs of smokers were also examined. Pulmonary function tests were measured in 97 male smokers (height 171.71±6.68 cm, age 36.49±13.06 years old) and compared with 95 male nonsmokers (height 171.79±8.81 cm, age 35.56±12.83 years old). The subjects underwent measurement of spirometric flow and volume. The following variables were measured: forced vital capacity (FVC), forced expiratory volume in one second (FEV1), maximal mid-expiratory flow (MMEF), peak expiratory flow (PEF), maximal expiratory flow at 75%, 50%, and 25% of the FVC (MEF75, MEF50, and MEF25 respectively). In addition, pulmonary function tests of 33 male smokers (height 172.79±11.94­ cm, age 38.30±6.65 years old) before and 10 minutes after administration of 200 µg salbutamol inhaler were measured. The results showed that most values of PFTs in smokers were significantly lower than those of non-smokers (p<0.001 for FVC, FEV1, PEF, MEF75, p<0.01 for MMEF, and p<0.02 for MEF50). However, there were not significant differences in MEF25 of smokers and non-smokers. There were significant correlations between the smoking duration and FEV1, PEF, MEF75, and MEF50 (p<0.05 to p<0.01), but correlations between smoking quantity and values of PFTs were not significant. The results also showed that all values of PFTs were significantly increased after salbutamol administration (p<0.05 to p<0.01). The enhancement in PEF, MEF75, and MEF50 was around 12% and that of MEF25 was 17%. The profound effect of smoking on PFT showed that smoking leads to constriction of large and medium sized airways which is mostly due to duration not to quantity of smoking. The airway constriction in smokers was reversible which, was mostly seen for medium sized airways. (Tanaffos 2003; 2(8): 23-30)

Pain after thoracotomy is one of the most severe surgical pains, being the most fundamental inhibitor factor in chest wall movement after surgery. The effect of interpleural morphine on pain after thoracotomy was evaluated in a double-blind and randomized study. In 16 patients, morphine sulfate 0.2 mg/Kg in 40 ml of 0.9% normal saline (N/S) was injected via interpleural (ip) catheter at the end of surgery. Meanwhile, 10 ml of 0.9% normal saline IV was administered [ipm group]. In 15 patients, 40cc of 0.9% N/S ip and concurrently morphine sulfate 0.05 mg/kg in 10cc of N/S IV were injected [ips group]. After first injection in the operating room, infusion of aforementioned solutions was continued every 4-hour, for 24 hours in ICU.The patients received supplementary doses of morphine IV in necessity to relief pain. By using facial pain scale (FPS), the degree of pain before and 30 min after drug injection was evaluated. The amount of supplementary morphine, side effects, sedation rate, and drainage of chest tubes were recorded over 24 hours. In ipm group, FPS was significantly lower than that of ips group over 24 hours postoperatively (p<0.0.5).Mean of the required supplementary morphine in ipm group over 24 hours, was significantly less than that of ips group.Sedation rate in ips group was significantly higher than that of ipm group (p<0.05) Based on this study, we concluded that administration of adequate dose of interpleural morphine can cause effective and favorable analgesia after thoracotomy. Furthermore, it does not have a common systemic side effect. (Tanaffos 2003; 2(8): 31-39)

To search the reliability of palpation technique in measuring tuberculin skin test and to compare the palpation technique with the ballpoint-pen technique. Setting: A dormitory for high school students. Participants: A total of 230 students were analyzed in this study; all of them were male and their ages ranged between 16 to 18 years. Measurements: All students were tested using 0.1 ml of purified protein derivative (PPD) containing 5TU (tuberculin unit) via the Mantoux method. Readings of tuberculin skin tests were done 72 hours later. Three readers measured the tuberculin skin test by palpation technique and another read it by ballpoint-pen technique, for each student. With the palpation technique, Confidence Interval (CI) was 95% (0.56-0.76), and kappa coefficient was 0.62. According to these results, there was good reliability between the three observers who made the measurements by palpation technique. Between the measurements that were made by palpation and ballpoint-pen technique, interclass correlation coefficients were found 0.94, and there was good correlation between the two techniques. We conclude that when the two methods were performed by experienced observers, the reliability of results were similar. (Tanaffos 2003; 2(8): 49-53)

Delays in diagnosis and start of effective treatment increase morbidity and mortality from tuberculosis (TB) as well as the risk of transmission in the community; therefore, an operational research directed at increasing our knowledge about the factors affecting these delays has an important role in improving the quality and effectiveness of National TB Programs (NTP). This nation-wide cross-sectional study was based on a structured interview with 400 newly diagnosed sputum smear-positive pulmonary TB patients aged over 15, registered at district TB coordination units of the country in a 3-month period in 2003 (from Mid Feb. to Mid May), to determine “the factors affecting the health care system delay". Median Total delay was 92 days (range, 7 - 445). Medians of Patient delay and Health care system delay were 20 (range, 1-381) and 46 (range, 1-444) days respectively; consequently they had a significant difference (p < 0.001). In multivariate analysis, Health care system delay has shown significant increasing association with age (p=0.039), presence of at least a negative sputum smear for Acid Fast Bacilli during the course of disease (p<0.001), attendance in a private clinic as the first health care system (p =0.01), and history of chronic respiratory disease (p =0.044) as well as a decreasing association with the number of symptoms at the first visit (p <0.001) and taking sputum smear or chest X-ray at the first visit (p <0.001). To reduce health care system delay, it is recommended that health care providers especially physicians in private sector be trained and retrained on TB (especially on the mentioned points in the results) at regular intervals. (Tanaffos 2003; 2(8): 55-64)

One of the most important subjects for health services is the estimation of the prevalence of pulmonary tuberculosis (particularly sputum – smear positive pulmonary tuberculosis cases). We suppose that there is a possible correlation between the prevalence of chronic cough and the sectional prevalence of pulmonary tuberculosis. A cross-sectional study was carried out in Rudsar in the year 1999. Rudsar is a town with a total population of 82658, 19505 families, which includes 2018 (2.44%) people, having history of more than 2 weeks cough, based on our census. Individuals with more than 2 weeks cough were eligible for this study. Tuberculosis suspects were referred to district health center, for each suspicious case, diagnostic procedures such as physical chest examination evaluation of BCG status, three sputum smears and, if needed, CXR were performed. Of 2018 individuals, 594 (29.4%) had typical scar of BCG. Chronic cough was confirmed by clinical work up in 761 participants. Among them, 403 patients (0.47% of Rudsar population) presented with productive cough sputum specimens were taken. Chest radiographs showed characteristic pulmonary tuberculosis lesions in 13(16.7%) of 79 patients in whom radiography was done on the basis of clinical findings. Five patients were diagnosed as sputum-smear positive pulmonary tuberculosis, and 3 new smear cases were diagnosed as new smear- negative TB cases. Sectional prevalence of sputum-smear positive patients and pulmonary tuberculosis between March 21 and June 20, 1999 were 8.5 and 12.1 in 100000 population respectively. If patients who were diagnosed within 9 months after the end of our study, according to health service system census, are taken into consideration, these rates will run to 30.25 and 47.12 respectively. Sensitivity, specificity, Positive Predictive Value (PPV), and Negative Predictive Value (NPV) for sputum smear and chest radiography were 62.5%, 100%, 100%, 94.4% and 100%, 92.9%, 61.5%, 100% respectively.In regard to diagnostic role of sputum – smear and chest radiograph in pulmonary TB, the difference between PPV (p=0.000), specificity (p= 0.03) and sensitivity (p = 0.000) was significant. Likelihood ratio for chest radiograph (34.26) was greater than sputum-smear (23.66)(p =0.000). Only 20% of the patients with pulmonary tuberculosis were identified via health service system (HSS) screening method in Rudsar, and the rest were diagnosed through recent study.Our findings suggest that the diagnostic power of chest radiograph is more than sputum smear; however, we think the HSS method for taking sputum wasn’t a controlled one. (Tanaffos 2003; 2(8): 65-70)

Adult mediastinal cavernous lymphangioma is a benign rare lesion originating from lymphatic system. It is usually asymptomatic. We have presented a 28-year-old man with dyspnea on exertion and palpitation. A mediastinal mass was discovered on CXR. CT findings revealed "non enhancing", "smoothly marginated", and "multilocular" mediastinal mass which had extended to superior mediastinum. Finally, pathological examination of the surgical sample indicated "cavernous lymphangioma". (Tanaffos 2003; 2(8): 71-76)