TANAFFOS
Year:2007 | Volume:6 | Issue:1 (21)|Papers Count:14

We are proud to say that after publishing 20 issues of our medical journal, "Tanaffos", the journal has gained vast popularity on an internal, regional and international scale which we could safely say it’s our pride enjoy. In the extensive research of medical sciences, especially in the vast scope of Respiratory Diseases such as Thoracic Surgery, Tuberculosis, Intensive Care, Tobacco related issues, Air Pollution, Environmental and Occupational Hazards, etc. and in the competitive world of medical journalism, perpetual publishing of our journal and ultimately its qualitative and to some extent its quantitative improvement could undoubtedly demonstrate the commitment and interest of the editorial team in order to have a permanent presence in this competitive field.

There are three main differences between hydatid cysts of the lung and those of the liver. All three are readily explained on the basis of anatomic difference between these two organs: 1. The liver is involved about five times more often than the lungs. The reason is that the majorio/ of ingested hexacanth embryos of the parasite, Echinococcus granulosus, about 30 microns in diameter, is carried to the liver 'in the portal system. There they are filtered out in liver sinusoids. No more than about 20% of these ova manage to escape the adult human liver to become trapped in the pulmonary capillaries.

Background: Hydatid disease is a parasitic infestation which is endemic in many sheep and cattle raising areas and is still an important health hazard in the world. The aim of this study was to compare the clinical features, radiologic accuracy, and the surgical approaches of pulmonary hydatid cysts among children and adults in Northwestem Iran.Materials and Methods: 445 patients treated for pulmonary hydatid cysts over the last ten years, were retrospectively evaluated. The patients were arranged in two groups. There were 383 adults (86%) and 62 children (14%) and their clinical, radiological and surgical characteristics of the pulmonary hydatid cysts were compared.Results: Unlike adults, in children the frequency of pulmonary hydatid cysts in males was significantly (p=0.0036) higher than in females (65% vs. 36%). Cough was the most common symptom in both groups. The frequency of hemoptysis was more common (p=0.0042) in adults (38%) than in children (19%). However, giant pulmonary hydatid cysts were more commonly found in children (p<0.05). Cystotomy with or without capitonnage was the most preferred method used in both groups. Postoperative complications (pneumothorax) developed in five adults and one child, and were more frequent in noncapitonnage procedures. Only one recurrence was observed in the adult group. The accuracy of chest x-ray was 84% and 74% in children and adults, respectively.Conclusion: Due to the high "accuracy of chest x-ray in diagnosis of hydatid cysts of the lung in both groups, it is recommended as the preferred method of diagnosis in endemic regions.

Background: Hydatid disease is caused by an infection with the cestode, Echinococcus granulosus and is endmic in Iran. Medical therapy and surgical management are two main treatments. The purpose of this study is to represent our ten-year experience in surgical management of patients with complicated pulmonary hydatid disease including cysts ruptured into the pleural space or bronchi, multiplicity, hemoptysis, large size cysts and coexistence with liver cysts.Materials and Methods: Medical records of 109 patients, who underwent surgery for the treatment of pulmonary hydatid disease in Masih Oaneshvari Hospital from December 1995 to October 2005, were reviewed. Among these patients, we selected our study group in accordance with the following criteria:1) Cyst rupture into the pleural space or bronchi, 2) Occupying more than two third of the hemithorax in radiological studies, 3) Multiple cysts, 4) Massive hemoptysis, and 5) Synchronous pulmonary and liver cysts.Results: Among the 109 patients with pulmonary hydatid cyst, 82 patients (59% male and 41% female) met the above mentioned criteria.The mean age of patients was 31.7 years (range 9-80 yrs). The cyst diameter was determined by radiological imaging. The mean diameter was 6.23 cm, and 13 patients had giant cysts (occupying more than 2/3 width of the hemithorax). In this study group 55 patients had ruptured hydatid cysts, 29 had multiple cysts, 11 had significant hemoptysis and 15 had synchronous pulmonary and liver cysts. All patients had undergone surgery with or without previous medical therapy. Our procedure of choice was thoracotomy, cystectomy and closure of the bronchial openings before irrigating the cavity with silver nitrate (0.5 %) soaked sponge. Pulmonary resection was done in 8 patients due to the irreversible parenchymal damage. Post operative complications occurred in 16 (19%) patients including residual pleural space in 8, broncho-pleural fistula in 2, pleural effusion in 1, pulmonary embolism in 1, osteomyelitis of stemum in 1,  laceration of diaphragm in 1, and inability to access the liver hydatid cyst after thoracotomy and post operative pulmonary insufficiency necessitating mechanical ventilation also in 1 patient. One patient died because of sepsis (she had been operated on for combined pulmonary and liver hydatid disease). In the 1 to 60 months follow up period, 2 recurrences occurred.Conclusion: Although post operative complications occurred in 19% of our patients, all were treated by conservative managements. This rate of complications was acceptable among patients with complicated hydatid disease. Our procedure of choice is draining the cyst; closing all the bronchial openings in the pericyst and leaving the pericyst cavity open into the pleural space.

Background: Myasthenia gravis is the most common disorder of neuromuscular junction and several treatment modalities have been described for its management. Thymectomyhas been employed as a treatment modality for several years. Plasma pheresis has also been supposed as an adjunct to thymectomy in several articles. In this study, we describe long-term results of thymectomy after plasma pheresis in myasthenic patients operated on in Shohada-e- Tajrish medical center from March 1996 to March 2001. Materials and Methods: Information related to patients was obtained from medical records. All 46 patients underwent plasmapheresis before thymectomy and were transferred to ICU (intensive care unit) postoperatively. The surgical approach in all patients was median stemotomy and complete removal of thymus gland. Long term results of surgery were obtained via calling the patients. By this manner 31 of 46 patients were followed up.Results: Forty-six patients including 36 women (78.3%) and 10 men (21.7%) with the mean age of 25.6% 11.8 years were operated on in this period of time. The mean duration of symptoms was 15.7 months before the surgery. No postoperative mortality was seen. Five patients (10.9%) developed postoperative myasthenic crisis which was minimal in 4 of them. The mean duration of ICU stay was 18.9 hours. Thirtyone of 46 patients were followed up with a mean duration of 7. 7 years. Twelve patients (38.7%) had complete remission without using any drug. Twelve patients (38.7%) had significant improvement via decreasing the drug dosage necessary to control their symptoms. Two patients (6.4%) had no change in their disease status after the operation and in 1 patient (3.2%) with thymic pathology of invasive thymoma, the disease worsened. Four patients (12.9%) had disease recurrence after a period of complete remission. Result of operation was more satisfactory in patients younger than 30 years (p<0.05%). Thymic hyperplasia foresees more favorable outcome compared to other thymic pathologies. The mean duration of time necessary to reach final results was 19.6 months.Conclusion: As a result of this study, thymectomy seems to be a successful treatment modality in myasthenic patients and should be performed as soon as possible during the disease course. Besides, plasma pheresis has a significant role in decreasing the complications and improving the results of thymectomy in myasthenic patients and long term follow up is necessary for accurate evaluation of final results of operation.

Background: Inhaled corticosteroids are indicated in children who have mild persistent asthma. Fluticasone propionate is a newer corticosteroid agent with higher potency compared with previous generations. However, still few dose-ranging studies have been investigated for optimal dosing of inhaled corticosteroids particularly in children with regard to the tolerability and safety of the drug. The primary purpose of this study was to compare and evaluate the efficacy and safety of fluticasone with beclomethosone in the treatment of childhood asthma unresponsive to non-steroidal medications and also in persistent, moderate and severe asthma. Materials and Methods: Seventy children, aged 6 to 14 years were enrolled in an open randomized trial with a parallel group design. Fifty-two children with moderate, severe or persistent asthma received fluticasone 100 mg twice daily for 12 weeks compared with 18 asthmatic children on beclomethasone 200 mg daily. The outcome was assessed by data on questionnaires, changes in clinical symptoms, and results of peak flow metery (PEFR).Moreover, safety was assessed by 24 hour urinary cortisol measurement at the beginning of the study and comparison of the data with urinary cortisol at the end of 12 weeks.Results: A total of 70 children between 6 to 14 years (33 girls and 37 boys) were randomized to start treatment with fluticasone or beclomethasone. From 70 children 13(18.6%) had a history of contact with pets during their life. At the beginning in beclomethasone group:88.9% had cough, 88.9% had post exercise cough, 66.7% had dyspnea and 72.2% had wheezing. In Fluticasone group: 75% had cough, 76.9% had post exercise cough, 46.2% had dyspnea and 59.6% had wheezing. After 3 months of therapy in beclomethasone group: cough was seen in 16.7%, post exercise cough in 11.1%, dyspnea in 11.1%, wheezing in 16.7% and in fIuticasone group: cough in 15.4%, post exercise cough in 11.1%, dyspnea in 1.9% and wheezing in 3.8%.Oata showed a better improvement in clinical signs of patients with fluticasone (p<0.05). Pulmonary function tests revealed better lung function in fluticasone group (p<0.05). In addition, 24 hours urinary cortisol level was measured at the beginning and after 12 weeks of therapy and it was within the normal range for both drugs.Conclusion: Fluticasone produced significantly greater improvement in lung function and control of asthma symptoms compared to beclomethasone and is efficient in the treatment of persistent, moderate and severe asthma in children. In addition these improvements were achieved with no greater degree of cortisol suppression compared with beclomethasone.

Background: Prostaglandins (PGs) can enhance tumor growth and metastasis by stimulating angiogenesis and invasiveness, in addition to apoptosis and immune surveillance. Microtubule-interfering agents induce cyclooxygenase-2 (COX-2) and PG biosynthesis and this might reduce the efficacy of paclitaxel. Preclinical studies suggest that treatment with a selective COX-2 inhibitor may augment the antitumoral effects of chemotherapy. Thus, we designed a phase II trial to evaluate the efficacy of the combination of paclitaxel, carboplatin and celecoxib in advanced non-small cell lung cancer.Materials and Methods: Thirty-seven patients were enrolled in this trial. The inclusion criteria were: chemotherapy-naïve advanced NSCLC (non-resectable locally advanced stage IIIA, stage IIIB and IV), age> 18 yrs. and performance status (PS) of 0-2 (ECOG). All patients were given paclitaxel (200 mg/m2) and carboplatin (AVC 6) on day 1, every 21 days and celecoxib (400 mg) daily.Results: Most of the patients were male and the mean age was 58 yrs. Old. Performance status 0, 1, and 2 were 8.2%, 40.5% and 51.3%, respectively. Four patients were in stage /IIA (10.8%), 12 patients in stage /IIB (32.4%) and 21 (56.8%) in stage IV. The overall response rate was 54%. Time to progression and median overall survival were 5.7 and 9 months, respectively. Only one patient had grade 3 anemia. There was no grade 4 cytotoxicity. Three patients had cytotoxic drug allergy.Conclusion: Based on this study, adding 400 mg celecoxib to the standard regimen (paclitaxel plus carboplatin) does not enhance time to progression and overall survival compared to historical data. Thus, we recommend combining higher dosage of celecoxib with other targeted agents in phase I/II trials.

Background: Pain control after thoracotomy is an important issue. "Optimal pain control methods" for decreasing the post thoracotomy pain are a matter of debate among many surgeons. Ideal methods should have high success rate, easy implementation and minimal complications. This study was designed to evaluate the effect of intrapleural injection of marcaine in comparison to systemic analgesics (Pethidine) on post thoracotomy pain.Materials and Methods: This clinical trial was designed to compare the efficacy of a systemic agent (control group) and infusion of analgesic drug (case group) through an intrapleural catheter for post thoracotomy pain relief. The subjects had undergone postero-lateral thoracotomy and the two groups were compared with regard to age, gender, education, smoking, alcohol abuse and history of infectious diseases. All data were statistically analyzed using chi-square and t- student tests and p<0.005 was considered as significant.Results: Frequency distribution of pain within the first 24 hours showed marked decrease in severity of pain in both case or control group (P=0.00).Mean differences in pain score within the first 24 hours was 2.18 in the case group and 2.13 in the control group. (P=0.68). No significant difference was detected between the two groups.Conclusion: For relieving post thoracotomy pain, intrapleural infusion of marcaine can be as effective as systemic agents (pethidine) with regard to the negligible side effects and feasibility of use in either post thoracotomy or traumatic patients, intrapleural route can be used for selected patients as the method of choice.

Background: The prevalence of asthma is known to be increasing especially in developed countries. Most studies assessing the prevalence of asthma in adults have used the "European Community Respiratory Health Survey" (ECRHS) protocol. The aims of this study were to determine the prevalence of asthma, asthma-like symptoms and smoking as well as the correlation of asthma symptoms and smoking among Urmia medical university students.Materials and Methods: An ECRHS questionnaire with additional questions about absence from class because of wheezing and/or dyspnea and smoking was filled for them.Results: One thousand five-hundred students with the mean age of 20.8±3.5 years filled out the questionnaires. Among them, 17.1% of males and 2.3% of females were current smokers. The most prevalent symptoms during the last 12 months were wheezing (19.7%), resting breathlessness (10.2%), exercise-induced cough (16.5%), and asthma attacks (3.1%).Asthma symptoms were strongly related to smoking (for all variables p<0.001) but were not related to sex (p>0.05), 5.4% had a history of absence from class because of wheezing or dyspnea.Conclusion: We found a relatively high prevalence of wheezing among young adult university students. Our findings suggest that cigarette smoking is common among young university students with asthma symptoms. Adequate public health measures are needed to prevent smoking among Iranian young adults, and medical students should be better educated with regard to asthma and the risks of smoking.

Background: CO/T -cell have a central role in protective immune responses to Mycobacterium tuberculosis (M. tuberculosis) protein antigens, but function of these cells in response to M. tuberculosis total lipid antigens has remained unclear. The present study was undertaken to detennine role of CO4+ T cells in the MDR-TB patients against M. tuberculosis total lipid antigens. Materials and Methods: CD4+ T-cells were isolated from MDR-TB patients and stimulated with M. tuberculosis total lipid antigens. Proliferative responses and cytokine secretion were assessed by MTT and EL/SA, respectively.Results: Our study results showed that proliferative responses of stimulated CO4+T-cells to M. tuberculosis total lipid antigens and IFN-y production in MDR-TB patients were significantly lower than those of the PPD-positive subjects (P<0.05) whereas, IL-4 production in the MDR-TB patients was elevated (P<0.05).Conclusion: Responses of CO4+ T -cells of MDR-TB patients to total lipid antigens was significantly lower than that of PPD positive healthy subjects. Therefore, it seems that M. tuberculosis lipid antigens, as protein antigens, have an important role in specific immune response.

Background: Adrenal insufficiency following initial treatment of active tuberculosis (TB) is a rare phenomenon. It is also one of the most important causes of mortality within the first few days of TB treatment. The present study evaluated this adverse effect of anti-tuberculous treatment.Materials and Methods: A prospective study was performed on TB patients hospitalized in Masih Daneshvari Hospital between 2004 and 2005. All patients had received standard anti-TB drug regimen. We evaluated pseudo-adrenal insufficiency in these patients.Results: The study group included 429 patients out of which 6(1.4%) developed adrenal insufficiency following anti-TB treatment. In all 6 patients, basal serum cortisol levels were measured which were below the normal range after treatment. No patient had clinical findings of adrenal insufficiency before initiation of anti-TB therapy. After treatment with dexamethasone, the general condition of patients improved. (The average response to treatment was 3.1±1.7 days). No mortality was reported during the treatment course or follow-up period.Conclusion: In TB patients, the adrenal reserve/ serum cortisol reserve level is low. Standard anti-TB drug regimen including rifampicin causes rapid catabolism of cortisol in tissues specially in the liver and lungs; therefore, serum cortisol level will be more decreased and consequently the patient develops adrenal insufficiency. As a whole, despite of the low incidence rate of this adverse effect, early diagnosis and treatment is essential to save the patient's life.

Chest wall abscess is a very rare presentation of extranodal Hodgkin's lymphoma. Only a few case reports have been found in this regard. Here, we describe a chest wall mass developed in association with tuberculosis in an 82-year-old woman.Radiologic examination revealed two masses outside of chest wall that lead to destructive changes in the manubrium of sternum. The diagnosis of Hodgkin lymphoma was made by open surgical excisional biopsy of the chest wall mass. This is a very unusual extranodal presentation of Hodgkin's lymphoma.

The term pulmonary-renal syndrome has been frequently used to describe the clinical manifestations of a great number of diseases in which pulmonary hemorrhage and glomerulonephritis coexist.Antineutrophil Cryoplasmic Autoantibody (ANCA) associated vasculitides include Wegener's Granulomatosis (WG), microscopic polyangiitis (MPA), renal limited pauci-immune glomerulonephritis and Churg-Strauss syndrome.Causes of pulmonary-renal syndrome which are more frequently associated with antineutrophil cytoplasmic autoantibodies are included MPA and WG. These diseases involve kidney as pauci-immune rapidly progressive glomerulonephritis.For MPA the estimated prevalence is 3-37 cases per million; and for WG It is approximately 3 per 100.000 persons that only 0.1 percent of patients are younger than 19 years. Pathologically, the major finding in renal biopsy is necrotizing glomerulonephritis accompanied by crescent formation in MPA and WG.A 10-year-old boy admitted to our hospital because of respiratory distress, hemoptysis, evidence of renal failure and glomerulonephritis (pulmonary- renal syndrome).Laboratory findings revealed biochemical evidence of renal failure and positive cytosolic anti-neutrophil cytoplasmic antibody (C-ANCA). Chest x-ray showed multiple round opacities with well defined margins in the right lung. Open renal biopsy showed necrotizing vasculitis with involvement of small and medium sized vessels.

A 47-year-old woman was referred to our hospital with history of occasional arthritissince two years ago. She also noted low grade fever, progressing fatigue, malaise, morning stiffness and occasionally dry coughs. She was treated as Rheumatoid Arthritis with irregular use of prednisolone and hydroxychloroquine but no improvement occurred Over the twenty days preceding the current admission, she experienced skin eruptions including red non-itchy palpable nodules on face, back and limbs. She did not mention any weight loss, sputum producing coughs or high grade fever. She denied tobacco use; she did not have any medical problem in her history. She used NSAIDs occasionally. At the time of hospital admission, she was afebrile and looked healthy. Vitalsigns were normal. She had bilateral expiratory wheezing in lungs, mild swelling in wrist joints, knees and ankles without effusion or deformity. All the joints had full passive range of motion. Skin examination revealed red-purple papules and plaques on forehead, back, elbow and dorsum of feet (fig 1).A painful 2x2 cm red nodule was seen on anterior surface of the right leg (Figure 2). The results of laboratory tests were: ESR: 40, CRP: positive, RF: negative, Ca: 9.5 and P: 4.7. Liver enzymes level and CBC were ANA, ANCA (C&P), Anti-ds DNA all were negative. CXR is shown in figure 3. It should be emphasized that she had not obtained any CXR previously during her illness.