Toll-Like Receptor 4 in Acute Respiratory Distress Syndrome: Good Time to Target?

Acute respiratory distress syndrome (ARDS) is considered a major cause of death in the world. ARDS is defined by life-threatening pulmonary edema and hypoxemia with a mortality rate of up to 40%. Recent advances in understating cellular aspects of the syndrome have shed light on possible new treatments and reduction of mortality. Toll-like receptors (TLRs) are pattern recognition receptors (PRRs) involved in adaptive and innate immunity. They are present in the alveoli and their activation can lead to inflammatory responses and finally acute lung injury. Among them, Toll-like receptor 4 (TLR4) is abundantly available on the epithelial cells of the alveoli and also on resident monocytes. TLR4 is one of the players that can promote alveolar damages during ARDS. Here, we focus on the TLR4 role in ARDS pathophysiology. We also present the potential therapies for the syndrome based on TLR4 inhibition

Dexmedetomidine Mechanism of Action: an update

Dexmedetomidine (PRECEDEX) is an imidazole derivative that is a highly selective a2 receptor agonist. Activation of the a2 adrenergic receptors by dexmedetomidine leads to both sedation and analgesia; with negligible respiratory and cardiovascular side effects. The drug is likely to be increasingly used for sedation and as an anesthetic adjunct

Toll-Like Receptor 4 in Ventilator-Induced Lung Injuries

Toll like receptors (TLRs) recognize pathogens and generate an immediate defense response by inducing the production of pro-inflammatory cytokines, which rapidly destroy or limit the pathogens. In their bridging role, TLR downstream signals link innate and adaptive immunity, particularly by mediating DC maturation and activation of pathogen specific T lymphocytes. These pathways lead to the activation of professional APCs, which is followed by enhanced expression of surface molecules, MHC and co-stimulatory molecules [CD40, CD80, CD86 and CD70].TLRs are expressed in a variety of cell types, mostly within the immune system where they have been linked to different cellular activation states, immune defense, maintenance of homeostasis, and various diseases. TLRs and related immunological pathways are being extensively studied for research, diagnostic and therapeutic purposes. Most mammalian species have between ten and fifteen types of TLRs. Ten functional TLRs (TLR1-10) have been identified in human.

Effect of pulmonary rehabilitation program on patients admitted to ICU:a comparative cross sectional study

Generally ICU patients are in critical status and need long stay in ICU. Pulmonary rehabilitation program (PRP) is considered as an important tool to improve outcome and shorten the length of stay in ICU. The aim of this study was to investigate whether PRP can affect outcome and duration of hospitalization in ICU patients. This study was performed in medical ICU of Labafi Nejad hospital, Tehran, Iran during 2012 and 2013. All of patients who had more than one day stay in ICU were included in the study. They underwent PRP. We compared length of stay, mortality rate and number of hospitalized patients within 2 years in patients with PRP and patients without PRP. In 2012, 155 patients and in 2013, 173 patients were admitted in ICU.  Admission period was 15 ± 2.7 and 11 ± 2.1 days, respectively (p< 0.001). Pulmonary physiotherapy showed no effect on patients’ outcome in which during 2012, 94 patients were discharged and 61 patients were died and in 2013, 98 patients were discharged and 64 patients were died (p=0.9). Our study shows that PRP can shorten hospitalization time which can indirectly decrease hospitalization costs but there is no effect on overall survival.

Midazolam Enhances Ureter Visualization in Children Undergoing Magnetic Resonance Urography

Introduction: Magnetic Resonance Urography (MRU) is a popular method for identifying uropathies in children. Some children are not cooperative for such examinations and are sedated. We decided to evaluate the effects of midazolam as a sedative drug on ureter visualization in patients undergoing MRU.Materials and Methods: The study was conducted in Paytkaht Medical Imaging Center, Tehran, Iran. Two hundred and three children with urologic diseases were divided into 2 groups. Patients in the non-cooperative group received midazolam prior to MRU.Results: Our findings showed that non-cooperative children had a better ureter visualization on MRU (P<0.01).Conclusions: Midazolam increased ureter visualization possibly by reduction in the ureter peristaltic motility. Therefore, its use could shorten the duration of MRU. It is beneficial to use midazolam in all children who undergo MRU.Keywords:  Diagnostic Imaging, MRI; Urography; Midzolam; Child; Ureter

Effects of opium inhalation on pulmonary volumes in smoking patients

       Historically, opium was used as a potent analgesic and to treat dyspnea and cough. It is documented that opium can increase exercise tolerance and relieve breathlessness. However, its overdose can suppress respiratory centers. The purpose of this study was to evaluate effects of opium on spirometric lung volumes.The study was done on two groups of patients referred to the lung clinic of Labbafi Nejad hospital. Group A was composed of 84 patients who were smokers and group B was made up of 40 patients who were smokers and opium addicts. Patients underwent spirometry and demographic questionnaires were collected. Significant differences were noted on lung volumes between two groups. Forced Vital Capacity (FVC) was 56 ± 4.6 % in Group A and 72 ± 4.7 % in Group B (P < 0.001). Difference on Forced Expiratory Volume in one second (FEV1) was also statistically significant, 53 ± 6.6 % in Group A versus 69 ± 4.4 % in Group B (P < 0.001). In this study, lung volumes were considerably larger in patients who were opium addicts and smokers compared to patients who were only smokers. Further studies are warranted to confirm these results, and such confirmation may lead to better understanding about role of opioids in respiratory diseases.

Inadvertent Transfusion of Two Incompatible Blood Units: A Case Report

Background: An incompatible blood transfusion may lead to hemolytic transfusion reactions and severe complications such as intravascular hemolysis, multiorgan failure, and even death. Prevention, early diagnosis, and treatments have the main roles to decrease transfusion complications. Cases Report: We present a case of a 43-year-old woman with a history of mandibular malignancy and facial reconstruction surgery who needed to blood transfusion due to a hemorrhage around her tracheostomy, and inadvertently 2 units of incompatible blood were transfused. The errors conduce to this issue and consideration to prevent and manage incompatible blood transfusions are discussed. Conclusion: This case showed that an effective technique for recognizing and avoiding transfusion mistakes is staff awareness of the potential errors at the bedside and in the laboratory. Furthermore, patients’ immunological status, early detection, and recognition of blood transfusion manifestation are critical factors for early diagnosis and treatment

Efficacy of High Dose Vitamin C, Melatonin and Zinc in Iranian Patients with Acute Respiratory Syndrome due to Coronavirus Infection: A Pilot Randomized Trial

INTRODUCTION: Our aim was to investigate the efficacy of vitamin C, melatonin, and zinc in patients with severe Covid-19. METHODS:  Twenty-one adult patients were randomized 1:1 to standard care alone or standard care plus IV vitamin C (2 g, q6hr), oral melatonin (6 mg, q6hr), and oral zinc sulfate (50 mg, q6hr) for 10 days. Patients were monitored for changes in hypoxemia and inflammatory markers. RESULTS: Both treatment modalities were effective to improve PaO2/FiO2 and oxygen saturation. However, there were no significant differences between 2 groups (P > 0.05). There were reductions in CRP, ESR, and LDH levels in both study groups, although not significant. No significant difference was noted in length of ICU stay between 2 groups (P = 0.3). CONCLUSION: Our study suggests that addition of vitamin C, melatonin, and zinc to standard care is not associated with considerable improvement in patients with severe Covid-19.&nbsp

Rate of Self-Extubation in Pediatric Intensive Care Unit Following Administration of Fentanyl, Midazolam and Midazolam-Fentanyl Combination: A Comparative Study

Background Self-extubation is a problem in pediatric intensive care unit (PICU) and can be harmful for children. Level of sedation is a determining factor for self-extubation. The aim of this study was to compare thr rate of self-extubation and duration of ventilation following different sedative modalities. Materials and Methods This prospective and randomized study was done in Mofid Children Hospital, Tehran, Iran from October 2015 to September 2016. One hundred and fifty seven children from 1 month to 15 years of age with normal consciousness level requiring mechanical ventilation were included.The rate of self-extubation, and duration of ventilation were compared among 3 groups; Midazolam group (n= 50) 0.1 mg/kg/hr, Fentanyl group (n= 50) 2 mcg/kg/hr., and Midazolam-Fentanyl group (n= 57); midazolam 0.05 mg/kg/hr and fentanyl 1 mcg/kg/hr. All administrations were IV. Optimal level of sedation was 2-3 using Ramsay score. Results: One hundred and fifty seven children were studied. The mean age of patients was 4.5 ± 1.5 years with an excess of boys (57.9% vs. 42.1%). Rate of self-extubation was lower in Midazolam-Fentanyl group; the difference was significant among 3 groups (p < 0.01). There was a significant difference in duration of ventilation in Midazolam- Fentanyl group compared the other groups (Midazolam group and Fentanyl group) (p < 0.001). Conclusion This study showed that combination therapy with Fentanyl + Midazolam was associated with lower rate of self-extubation and shorter duration of ventilation. In addition, this combination therapy seems safe

Analysis of the Descriptive Lingual Level of Travel Diaries of Hajj Sayyah based on Fairclough’s (Critical Discourse Analysis) Pattern

The Rhree-Dimensional Model of Critical Discourse Analysis Allows the Analyst to Examine the Reflection of Ideology and the Domination of the Power System by Intertextual Description of the Linguistic Signs and their Social Interpretation and Explanation. The Purpose of this Study is to Investigate the Ideology and Domination of the Power System in Different Intertextual and Extra-Textual Layers of Hajj Sayyah Memoirs. Research Findings Show that the Level of Description, Method and Frequency of vocabulary use, indicators, action verbs, positive and definite verbs, simple Sentences, and the Naming Process, at Three Levels of Vocabulary, Syntax, and text have a prominent relationship with the power system. In the section of Relational Values, the Use of Quotations, the Dominance of the Declarative Aspect, the Use of Pronouns Commensurate with the Social Dignity of the Reference, and the Organizational Aspects of the Dialogue are among the Factors Representing the Relationships between Actors and commensurate with their position of power and the relationship between Power and Ideology. At Expressive Values’ Level, the Non-Metaphorical Nature of Language and the Use of Few Examples of it, Show the Author's explicit and reckless confrontation with the system of power. At the text Level, Two Different Constructions are Used in this Work. The Conclusion is that in the Reviewed work, the System of Power and Position of the Writer Regarded to it, has a Prominent Effect on the Use of Linguistic Signs at Different Lexical and Syntactic Levels