Ventilator-associated Pneumonia: A Study of Patients admitted in Internal Intensive Care Unit of Ali Asghar Hospital, Shiraz

Introduction: Ventilator-associated pneumonia is defined as a pneumonia occurring in patients within 48 hours or more after intubation with an endotracheal tube or tracheostomy tube and which not present before. The main objective of this study was to determine prevalence, predisposing factors and outcomes for ventilator associated pneumonia in an internal intensive care unit in a tertiary hospital. Material and Methods: In this retrospective review, all adult intensive care unit admitted patients at Ali Asghar Hospital with clinically and radiologically suspected ventilator-associated pneumonia between March 2009 and May 2010 were considered. The following data were recorded for each patient: demographic data, culture densities, chest radiological findings, pathogen(s), age, white blood cell count (WBC), presence of comorbid diseases, duration of hospital stay prior to diagnosis, and hospital survival. Data was assessed with SPSS software version 15 compatible for windows. Results: There were 49 patients in this study and most of the patients (69.3%) were males. Most of the patients (65.3%) were in more than 60 years age group of whom males were dominant. The most common risk factor was smoking, nasogastric tube, prolong duration of hospitalization, hospital admissions more than 2 times, prolong duration of intensive care unit admission, decreased level of consciousness and prolong ventilator support. The most common organism isolated was acinetobacter. Most of the patients were died (59.1%) of whom most were males. Discussion and conclusion: This study demonstrated that ventilator associated pneumonia is an important nosocomial infection among patients receiving mechanical ventilation in a community hospital and it is associated with greater hospital mortality rates and longer lengths of stay in the intensive care unit and hospital. Prevention is better than cure. Ventilator associated pneumonia is a well preventable disease and a proper approach decreases the hospital stay, cost, morbidity and mortality

Eosinophilic Ascites and Duodenal Obstruction in a Patient with Liver Cirrhosis

Eosinophilic gastroenteritis (EG) is a rare disease characterized by eosinophilic infiltration of portions of the gastrointestinal tract. Eosinophilic ascites is probably the most unusual and rare presentation of EG and is generally associated with the serosal form of EG. Hereby, we report a case of eosinophilic ascites with duodenal obstruction in a patient with liver cirrhosis. A 50-year-old womanwas admitted to our hospital because of abdominal pain, nausea, bloating, and constipation. She had a history of laparotomy because of duodenal obstruction 2 years ago. Based on clinical, radiological, endoscopic, and pathological findings, and given the excluding the other causes of peripheral eosinophilia, the diagnosis of eosinophilic gastroenteritis along with liver cirrhosis and spontaneous bacterial peritonitis was established. Based on the findings of the present case, it is highly recommended that, in the patients presented with liver cirrhosis associated with peripheral blood or ascitic fluid eosinophilia, performing gastrointestinal endoscopy and biopsy can probably reveal this rare disorder of EG

The Relationship between Nocturnal Hypoxemia and Left Ventricular Ejection Fraction in Congestive Heart Failure Patients

Congestive heart failure (CHF) is a major cause of mortality and morbidity. Among patients with heart failure, sleep disordered breathing (SDB) is a common problem. Current evidence suggests that SDB, particularly central SDB, is more prevalent in patients with CHF than in the general population, but it is underdiagnosed as SDB symptoms that are less prevalent in CHF.The main aims of this study were to determine the relationship between nocturnal hypoxemia and left ventricular ejection fraction in patients with chronic heart failure. Bymeans of echocardiography, 108 patients with left ventricular ejection fraction ≤45%weredivided intomild, moderate, and severe CHF. Hypoxemia was recorded overnight in the hospital and was measured by portable pulse oximetry. In the 108 patients with CHF, 44 (40.7%) were severe, 17 (15.7%) moderate, and 47 (43.6%) mild CHF. 95 (88%) of patients with CHF had abnormal patterns of nocturnal hypoxemia suggestive of Cheyne-Stokes respiration. Ejection fraction correlated negatively with dip frequency. There was no correlation between nocturnal hypoxemia with BMI and snoring. This study confirms strong associations between sleep apnea and heart disease in patients with CHF. Overnight oximetry is a useful screening test for Cheyne- Stokes respiration in patients with known heart failure

99mTc-MIBI Lung Scintigraphy in the Assessment of Pulmonary Involvement in Interstitial Lung Disease and Its Comparison With Pulmonary Function Tests and High-Resolution Computed Tomography

Abstract: The differentiation of active inflammatory processes from an inactive form of the disease is of great value in the management of interstitial lung disease (ILD). The aim of this investigation was to assess the efficacy of 99mTc-methoxy-isobutyl-isonitrile (99mTc- MIBI) scans in distinguishing the severity of the disease compared to radiological and clinical parameters. In total, 19 known cases of ILD were included in this study and were followed up for 1 year. Five patients without lung disease were considered as the control group. The patients underwent pulmonary function tests (PFTs) and high-resolution computed tomography scans, followed by 99mTc-MIBI scanning. The 99mTc-MIBI scans were analyzed either qualitatively (subjectively) or semiquantitatively. All 19 ILD patients demonstrated a strong increase in 99mTc-MIBI uptake in the lungs compared to the control group. The 99mTc-MIBI scan scores were higher in the patient group in both the early phase (0.24[0.19–0.31] vs 0.11[0.10–0.15], P<0.05) and the delayed phase (0.15[0.09–0.27] vs 0.04[0.01–0.09], P<0.05) compared with the control group. A positive correlation was detected between the 99mTc-MIBI scan and the high-resolution computed tomography (HRCT) scores (Spearman’s correlation coefficient ¼ 0.65, P<0.02) in the early phase but not in the delayed phase in patients (P>0.14). The 99mTc-MIBI scan scores were not significantly correlated with the PFT findings (P>0.05). In total, 5 patients died and 14 patients were still alive over the 1-year follow-up period. There was also a significant difference between the uptake intensity of 99mTc-MIBI and the outcome in the early phase (dead: 0.32[0.29–0.43] vs alive: 0.21[0.18–0.24], P<0.05) and delayed phase (dead: 0.27[0.22–0.28] vs alive: 0.10[0.07–0.19], P<0.05). The washout rate was �40 min starting from 20 min up to 60 min and this rate was significantly different in our 2 study groups (ILD: 46.61[15.61–50.39] vs NL: 70.91[27.09–116.36], P¼0.04). The present study demonstrated that 99mTc-MIBI lung scans might distinguish the severity of pulmonary involvement in early views, which were well correlated with HRCT findings. These results also revealed that 99mTc-MIBI lung scans might be used as a complement to other diagnostic and clinical examinations in terms of functional information in ILD; however, further investigations are strongly require

Sporadic Lymphangioleiomyomatosis Disease: A Case Report

Pulmonary Lymphangioleiomyomatosis (LAM) is a rare disease of the lung and lymphatic system that primarily affects women of childbearing age. LAM is a progressive disease with a terrible prognosis, which worsens over time and is extremely difficult to treat. In this study, we discuss the case of a 31-year-old woman with LAM who was initially misdiagnosed with leiomyoma and the way that led to a true diagnosis and effective treatment. Following a precise diagnosis based on comprehensive clinical data and particular immunohistochemical tests, sirolimus treatment was initiated, and the patient entirely responded to the treatment. This case report demonstrated that LAM is an uncommon condition that is challenging to diagnose, which causes its treatment to be delayed

Authors’ response to letter—COPD in exclusive narghile smokers: Some points to verify

We greatly appreciate the thoughts Dr Helmi Ben Saad has shared with us about the prevalence of chronic obstructive pulmonary disease in hookah smokers. We believe that there are proportional differences in the level of pulmonary function among the various races and communities. Neither Iran nor other Asian countries have established reference ranges for the level of pulmonary function in healthy subjects. Given that we used spirometric norms for both case and control groups, it seems that it cannot cause diagnostic problems. We agree that the use of a fixed threshold such as 80% of predicted is associated with age- and heightrelated bias, and the use of Z-scores removes the agerelated bias. However, it is possible that the Z-score underestimates airflow limitation severity in patients over 60 years of age with severe functional impairment. 1 Both percentage predicted and Z-scores have limitations when classifying the severity of obstructive lung disease or defining prognosis. The American Thoracic Society (ATS) has developed criteria which suggest a significant postbronchodilator forced expiratory volume in one second (FEV1) and/or forced vital capacity (FVC) response of 200 mL or greater and 12% improvement from baseline.2 In addition, the European Respiratory Society (ERS) recommend using the percent change from baseline and absolute changes in FEV1 and/or FVC in an individual subject to identify a positive bronchodilator response.3 Spirometry cannot measure residual volume or total lung capacity (TLC), so the gold standard for detection of a restrictive lung pattern is body plethysmography, which can measure TLC. According to the ATS/ERS guidelines, restrictive pattern in spirometry consists of a reduction in vital capacity and increases in the ratio of FEV1 to FVC > 85–90%.4 However, this recommendation has not been validated. We agree that new standards are more appropriate

Efficacy of care in Fatemeh Zahra hospital’s ICU wards according to APACHE II score

Background: The prediction of death in intensive care units is done by using scoring systems (eg APACHE II) which assess disease severity. This study was performed in Intensive Care Units (ICUs) of Boushehr&rsquo;s Fatemeh Zahra hospital to evaluate the efficacy of APACH II system and also to compare the observed mortality with the predicted mortality rate and also to that of some creditable centers. Material and Methods: This cross-sectional, descriptive and analytical study was performed on one hundred patients with critical conditions on the day of their admission to the ICU wards. Data were analysed by Chi Square, student T, sensitivity, specificity, positive and negative predictive values, ROC curve and spearman correlation coefficient using SPSS version 13. Results: The mean score in internal medicine ICU (60 patients) was15.45 and in surgery&rsquo;s ICU (40 patients) was 11.1. There was a positive correlation between the acquired score and mortality (p<0.001 and correlation coefficient=0.4). Mortality in our ICUs was more than that of more developed centers with respect to APACHE II score. The observed mortality rate was 31% and the predicted death rate was 19.79%. The area under ROC curve was 0.76 (CI95%=0/65-0/86). There was also a positive correlation between the acquired score and duration of ICU admission (p=0.009 and correlation coefficient=0.262). Conclusion: The APACHE II score is appropriate for predicting mortality in our ICUs. Our observed mortality rate was greater than the predicted death rate, in comparison to some developed centers which show no significant difference. Therfore it appears that we must improve our intensive cares to reduce mortality

A Comparative Analysis of Saffron and Methylprednisolone on Bleomycin-Induced Pulmonary Fibrosis in Rats

Background: The purpose of this study was to compare the effects of saffron and methylprednisolone on bleomycin-induced pulmonary fibrosis in rats. Methods: This study was conducted in Bushehr, southern Iran in 2017.The animals were divided into four groups of five rats each. Three groups were injected with a single intratracheal dose of bleomycin (5 mg/kg). The fourth group was administered with normal saline at the same volume (200 µl). Saffron extract dissolved in water was given to one group (100 mg /body weight) orally while intraperitoneal injection of methylprednisolone (2.5 mg/kg) injected to another one for 16 days. The rats were sacrificed 28 days following surgery and their right and left lungs were removed and washed for measuring lung indices, myeloperoxidase activities and finally histopathological examination. Results: Injection of bleomycin caused decrement of body weight aggravated by intraperitoneal methylprednisolone treatment. Lung indices were increased in the bleomycin-treated group compared with the control, while methylprednisolone, unlike saffron, had no preventive effects on it. Both saffron and methylprednisolone treatment prevented the increase in lung myeloperoxidase as a destructive enzyme. In addition, excessive collagen deposition and thickening of alveolar septa were significantly prevented with saffron treatment as compared to methylprednisolone injection following hematoxylin and eosin staining. Conclusion: Saffron with established antioxidant properties could prevent some detrimental effects in bleomycin-induced pulmonary fibrosis even more than methylprednisolone injection known as a standard therapy in this murine model. More investigations must be carried out to examine the beneficial or harmful effects of this remedy