Tanaffos Respiration Journal
Volume:2 Issue: 3, Summer 2003

Sepsis remains a major cause of hospital-based mortality and morbidity, especially in ICU. It is estimated that there is 100000 to 500000 episodes of sepsis each year in the United States that involves 25%of patients admitted in the ICU, causing 80000 deaths each year.Some major variables may create discrepancies in predicting the outcome in critically ill patients. These are gender, preinfectious, preoperative, immune and/or genetic status, age, iatrogenic, and nosocomial events. In some studies, it is demonestrated that low circulating cholesterol concentration is associated with a greater mortality rate. Cholesterol is the basic element of cell membrane and is essential in extensive tissue repair processes for example in sepsis or after trauma. Setting: medical intensive care unit of Hazrate Rasool-e-Akram and Firoozgar hospitals. Design: cross-sectional case series. Patients: totally 52 participants 26 of whom were septic and the rest were not (according to sepsis criteria). None of the patients had sepsis at the time of admission to the ICU. The patients were matched for demographic variables. Interventions: blood samples were drawn on the admission to the ICU and then twice weekly. Statistical Analysis: Results were expressed as (means±2SE) and analysed by SPSS version 10.00.The required tests were chi-square and t-tests. The male to female ratio was 0.92. In septic patients only 38.4%of them had positive blood culture. The most common organism was gram negative enteric pathogen (Klebsiella and E. coli).The average time of hospitalization in septic patients was 7.3± (1.8). There was no significant statistical difference between two groups (p value=0.537). The average primary cholesterol level in septic patients did not show significant differences with another group. However, the last cholesterol level was lower in septic patients. There were statistically significant correlations between the last cholesterol level and being septic. (p value=0.042). The mortality rate was higher in septic group than the other group (p=0.000). Patients with low circulating cholesterol levels are at risk for lethal infections especially severe sepsis. The cause could be due to the role of cholesterol in membrane lipid, microviscosity, decreasing the exposure of membrane proteins, and reducing membrane function. Also, adipose tissue could function as macrophage cells and secrete proinflammatory mediators. (Tanaffos 2003; 2(7): 11-16)

In patients suspected of having lung cancer but with no evidence of endobronchial lesion, biopsies taken by transbronchial, percutaneous or open lung surgery can contribute to diagnostic yield but each with their limitations and complications. Recently, cytologic analysis of bronchoalveolar lavage specimens has been shown to improve the diagnostic yield for peripheral lesions. The objective of this study was to determine the value of bronchoalveolar lavage cytology in diagnosing peripheral lung cancer in Imam Khomeini Hospital. We performed a study among 47 admitted patients with biopsy proven peripheral lung cancer in whom bronchoalveolar lavage cytology was studied. In patients with a peripheral lesion, BAL was positive for malignant cells in 36.2%. Bronchoalveolar lavage cytology was proved to be a valuable diagnostic tool in peripheral lung cancer in our country. (Tanaffos 2003; 2(7): 7-10)

Considering the importance of rapid and definite diagnosis and care of ICU admitted patients with clinically documented pleural effusion, this study was conducted to evaluate the effects of thoracentesis in changing the first diagnosis and care of pleural effusion. In this prospective study, of those who were admitted to ICU, 30 patients with physical and radiographic evidence of pleural effusion, without having contraindications to thoracentesis, were selected and routine thoracentesis was done. Biochemical, cytological, and microbiological tests were performed. There were 12(40%) male and 18 (60%) female with the mean age of 65.6±17.8 years. Among the reasons for MICU admission, hypoxic respiratory failure is the most common cause (21 patients, 70%), and other causes were “Acute on Chronic Respiratory Failure” (ACRF) in 6 patients (20%). The obtained effusion was transudate in 19 patients (63.3%), a noninfectious exudate in 7 patients (23.3%), and an infectious exudate in 4 patients (13.3%). There were significant differences between the diagnosis made before and after thoracentesis in 17 patients, 56.7% (p< 0.05). In 13 patients (43.3%), definite diagnosis after thoracentesis was the same. Also, in 16 patients (53.3%) based on thoracentesis finding the treatment plan was changed (p<0.05). We concluded that thoracentesis should be performed routinely in ICU patients having pleural effusion. This safe and cheap procedure may provide large gains in diagnosis, treatment, and even prognosis. (Tanaffos 2003; 2(7): 17-23)

Mortality from tuberculosis is high even in the chemotherapy era. Our study determines the predictor role of lymphocyte count in the mortality of non-HIV tuberculous patients. This case- control study was performed retrospectively in a university hospital, which is a secondary and referral center for tuberculosis in Iran. All documented pulmonary tuberculosis cases that had died while being hospitalized in TB wards during the year 2002 were enrolled. Equal number of documented tuberculosis who had been discharged from hospital with good conditions were also enrolled by simple randomized selection. All pertinent data including the first documented hematologic indices of the cases were gathered and analyzed using X2, logistic regression, and non- parametric tests. During the last year, 33 patients died from tuberculosis with an average age of 53 ± 16.5 yr. [11(33%) were female]. The mean lymphocyte percent in CBCs taken from the case group was 15.5 ± 10.2 comparing to 27.1 ± 9.8 for the control group. The frequency of lymphocyte counts below 1000 was 11 (37%) for the cases and 5 (15%) for the controls. The frequency of lymphocyte counts below 15% was 21 (67%) in the case group compared to 3 (9%) for the control group. Both results showed significant differences between the two groups (P = 0001). The odds ratio for total lymphocyte count deficiency was 3.5 and the odds ratio for < 15% was 27. This study revealed that lymphocytopenia may be used as a proper measure for determining mortality risk in non-HIV pulmonary TB patients. However, it seems necessary to confirm this new finding with introspective studies using broader sample sizes. (Tanaffos 2003; 2(7): 25-31)

Besides charging the patients with outstanding costs, tuberculosis (TB) causes high mortality and morbidity in a country. We studied the sensitivity, specificity, positive and negative predictive values as well as the efficiency of buffy coat smear test in patients who were pulmonary TB suspects. This research was conducted at Massih Daneshvari Hospital, National Research Institute of Tuberculosis and Lung Disease (NRITLD). According to clinical and radiographic records of 50 pulmonary TB suspects, five ml of blood along with smear and culture of sputum were collected. The research method was a clinical trial (Diagnostic test type), and the technique was of observational-interview type. Six buffy coat smears were obtained by Ficoll-Hypaque sedimentation method while the samples were stained by Ziehl-Neelsen stain. On sputum examination, 32 patients (64%) were B.K positive while 22 (44%) had positive sputum culture for Mycobacterium tuberculosis. Buffy coat was positive in 4 patients (8%). In comparison with sputum smear and culture, buffy coat had sensitivity of 12.5% and 13.6%, specificity of 100% and 96.4%, positive predictive value of 100% and 75%, negative predictive value of 39.4% and 58.7%, efficiency of 44% and 60% respectively. In regard to the high specificity of buffy coat as compared to sputum smear (100%) and sputum culture (96.4%), it is possible to consider buffy coat as a method for screening tuberculosis patients that cannot expectorate sputum. Since buffy coat method has a high positive predictive value as compared to sputum smear (100%), it could replace other unavailable accurate methods like sputum culture and PCR and be used as a substitution for sputum smear. (Tanaffos 2003; 2(7): 41-45

Tuberculosis is a common infectious disease these days; it has the highest mortality rate among all infectious causes only after HIV/AIDS. The emergence of tuberculous bacillus species resistant to multiple drugs has become a serious global threat to the human health. Drug resistance is either acquired with the initial infection (from a host harboring resistant tubercle bacilli) or develops during treatment with antituberculous chemotherapeutic agents because of poor patients compliance or inadequate/ inappropriate treatment regimens. This study has been done to evaluate drug resistance and to determine the type of resistance in drug resistant tuberculosis patients. The files of patients hospitalized during the past 2.5 years in Massih-Daneshvari clinical mycobacteriology ward due to suspected drug resistant tuberculosis were evaluated. Those who had a sputum antibiogram indicating resistance at least to one anti-TB drug were included in the study. Data, including demographic data, radiologic findings, sputum smear, sputum culture, and antibiogram were recorded in a specified questionnaire. Analysis was done for central indices using the SPSS software. Forty-three cases met the inclusion criteria. Twenty-seven (63%) were male and 16(37%) were female with the age range of 16-80 years (mean ±SD, 36.9 ±16.76). Twenty-five cases (58%) were Afghan and 13(30%) were Iranian (Other nationalities had not been recorded). Antibiograms of 38 patients (88%) showed resistance at least to isoniazid and rifampicin; these patients were considered as multidrug resistant (MDR) cases. In 24 cases (56%), the Mycobacterium tuberculosis was resistant to all four-drug isoniazid (INH), rifampicin (RIF), streptomycin (STM), and ethambutol (EMB). Thirty-six patients (85%) had resistance at least to STM, and 26 patients (60%) were resistant at least to EMB. Bacillus drug susceptibility to pirazinamide (PZA) was not specified. Most drug-resistant cases of TB were seen among Afghan emigrants. Ninety-five percent of cases had a history of treatment at least once, and the resistance was secondary (acquired). Despite discontinuation of streptomycin usage as an anti-TB drug in Iran in the recent years, the most common type of resistance was related to this drug, occurring in 85% of cases. Confirming different studies in other countries, the lowest resistance to the first line anti-TB drugs was for EMB, detected in 56% of cases. (Tanaffos 2003; 2(7): 47-51)

Tuberculosis is still a major health problem around the world. Malnutrition is frequently seen in TB patients. One of the important minerals being investigated in the malnutrition study is zinc.Deficiency of minerals in TB patients especially zinc has been reported in many cases. The aim of this study was to determine the effect of oral zinc supplements on the Sputum conversion of TB patients. This research was a randomized, double blind, placebo- control trial that was conducted in National Research Institute of Tuberculosis and Lung Disease (NRITLD). Patients with confirmed pulmonary tuberculosis having positive smears and cultures were divided by simple randomization into two groups i.e.: case and placebo groups. To the individuals of the case group, 0.5% zinc sulphate solution with a dose of 15mg/day was administered. Meanwhile in the placebo group, distilled water (as a placebo) with the same dose as zinc sulphate was given. Both groups received standard cat-I treatment. Patients from both groups underwent regular clinical investigation and smear test on days 0, 15, 30 and 60 and results were studied. Out of 24 patients in the treatment group and 20 patients in placebo, smears of 6 individuals (25 %) in case group and no individual in placebo group became negative at the end of fifteenth day (p<0.05).Smears of 17 (70.8 %) in intervention group and only 8 (40%) in placebo group became smear negative at the end of first month (p<0.05). At the end of second month, all patients in both groups became smear negative. According to the conclusions reached from this study, it seems that sputum conversion among the case group which used oral zinc sulphate supplement was much faster. (Tanaffos 2003; 2(7): 53-60)

Tuberculosis is one of the most ancient recognised diseases of human being which remains as an important obstacle for public health, despite numerous scientific advances made in the recent decades.Delay in treatment of tuberculosis due to socieoeconomic factors in addition to HIV epidemic increases the number of undiagnosed smear positive patients in communities. The patient’s delay and physician’s delay in diagnosis and treatment, inadequate therapy, errors in prescribing accurate regimens, financial problems of patients in taking drugs, lack of patient’s knowledge about the regular use of drugs and interruption of treatment all result in the emergence of drug resistant tuberculosis which adds to the difficulties in the management of this obstacle. Regarding the difficulties faced in treatment of tuberculosis, determining factors responsible for treatment failure and the consequently developing resistance is essential. This is a case control and sequential study which consists of hospitalised and out patient TB cases who have remained smear positive despite full course of anti-TB treatment. Eighty patients with this characteristic were compared with 80 controls who have responded to treatment. Eighty cases (44 females, 36 males) with median age of 28 yr. (15-73) were compared with eighty controls (41 females, 39 males) with median age of 29 yr. (16-70). There were no differences between two groups regarding nationality (Iranian vs. Afghan) (p>0.05) and economic status (p>0.05). There was significance difference regarding educational level of two groups, as it was significantly higher in control group (p<0.05). There was no significant statistical difference between two groups when living place was considered (urban, suburb, village) (p>0.05). The final interesting findings were high usage rate of four drug regimen and DOTS strategy in control group in comparison with the patients with treatment failure. (p<0.05, p<0.05, respectively). If the time from the onset of patients symptoms to the initiation of proper treatment (total delay) was more than 8 weeks, no significant difference was noted. However, if this time period was less than 8 weeks, significant difference was detected (p<0.05). This study shows that an important factor in preventing from treatment failure and emergence of resistant forms is the immediate referral of the patient to physician (less than 8 weeks) resulting in prompt diagnosis and treatment. Finally, DOTS strategy, early diagnosis, correct treatment of tuberculosis, patient’s knowledge about tuberculosis, how to use and side effects of anti-TB drugs and duration of treatment all should be considered as effective factors for prevention of anti tuberculosis treatment failure and emergence of drug resistant bacilli. (Tanaffos 2003; 2 (7): 61-68)