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The complications associated with transfusion of blood products in the intensive care unit are under diagnosed and could be associated with significant morbidity and mortality. They range from innocuous febrile reactions to hepatitis, human immunodeficiency virus (HIV), major incompatibility reactions and sepsis with life threatening sequel. On the bright side, with the advent of new screening methods, the incidence of HIV and hepatitis C transmission has dropped dramatically. In this review, we intend to summarize the commonly encountered complications associated with blood transfusion for the critical care staff. The first part deals with the complications of transfusion pertaining to each component of the blood i.e.granulocytes, red cells, platelets, and serum. The second part, deals with infection-related and other uncommon complications of transfusion.

Background: Interstitial pulmonary fibrosis (IPF) is a progressive fibrotic interstitial lung disease with a distinct histopathological form referred to as usual interstitial pneumonia (UIP). Evidence has indicated that a local renin- angiotensin system is present in distal lung parenchyma. Expression of the component of this system is present in a number of fibrotic lung diseases. In this study, we assessed the association of Insertion/Deletion (I/D) polymorphism of angiotensin- converting enzyme (ACE) gene in IPF.Materials and Methods: By using semi-nested PCR, we determined the I/D polymorphism of ACE gene in 23 paraffinembedded open lung biopsy specimens from patients having clinical and imaging findings of IPF and pathologic diagnosis of UIP at National Research Institute of Tuberculosis and Lung Disease (NRITLD). Afterwards, we compared the results with I/D polymorphism of ACE gene in a healthy control group (n= 88).Results: The frequency of I allele was 71.7% (33 out of 46) and the frequency of D allele was 28.3% (13 out of 46). The frequent genotype was I/D (56.5 %) which was statistically significant comparing with healthy group (27.3 %). We had no D/D genotype .There was a difference in the distribution pattern of ACE genotype between patients and controls (P<0.05).Conclusion: Our study revealed an association between carriage of I allele and I/D genotype in IPF.

Background: Chest tube is indicated in many situations and can be life saving in certain patients. Some of the chest tube complications are related with the number of its holes. Tube length is associated with other complications. The present study was performed with the aim of comparing two types of chest tubes, one with several holes and the other with a single hole.Materials and Methods: A randomized clinical trial was performed on 100 patients in Imam Hossein Hospital. Patients were randomly divided into two groups, and each group used one type of tube, one with several holes and the other with a single hole. Radiographic pattern, duration of use, complications, and need for a second tube were compared in the two groups.Results: There was no significant difference between the two groups regarding age, sex, duration of use, reason for tube insertion, clinical findings and laterality of chest tube placement. Hemothorax was significantly observed more frequently in radiographs obtained 1 hour and one-day later. In the 3rd day, two groups were similar in terms of hemothorax. Inadequate drainage was a complication observed in those with single hole tubes. Kinking was a complication seen in patients with multiple hole tubes. None of the patients needed second tube placement.Conclusion: There was no significant difference between the two tubes regarding their function but hemothorax occurred more frequently in those with multiple hole (conventional) tubes. Thus, we recommend the use of single holes tubes. Mass production of these tubes is cost effective considering less production costs and similar function.

Background: In spite of established guidelines developed by the American Thoracic Society (ATS), Infectious Disease Society of America (IDSA) and Centers for Disease Control (CDC), there is no consensus among physicians regarding hospitalization and choice of antibiotics for management of community- acquired pneumonia (CAP).This study was conducted to determine the percentage of patients appropriately assessed for admittance and the antibiotic treatment selections that were in accordance with the established guideline criteria.Materials and Methods: This retrospective chart review study was conducted at the National Research Institute of Tuberculosis and Lung Disease (NRITLD), Masih Daneshvari Hospital during 2005-2006. Patients with a definite diagnosis of CAP were selected and entered the study. The previous IDSA, ATS and CDC guidelines and the more recent IDSA/ATS CAP guidelines were all used to evaluate the management of patients admitted with CAP. Patients were excluded if information was not sufficient.Results: A total of 31 patients were reviewed. Of the 31 patients included in the study, 24 (77%) could have been treated with outpatient regimens. Six of 31 cases (19%) had been treated with regimens consistent with all three (IDSA, ATS, and CDC) guidelines. Twelve of 31 cases (39%) had corresponded to the previous treatment recommendations from ATS. The management of the remaining 13 patients (42%) had not corresponded to any of the mentioned guidelines. When compared to the recently published joint guidelines of ATS/ IDSA, 12 of 31 cases (39%) had appropriately corresponded to the treatment recommendations.Conclusion: According to this study only one fifth of the cases reviewed could have been treated on an inpatient basis. Considering the standard guidelines 42% of the patients did not follow the recommendations from evidence-based guidelines. The enforcement of guideline usage through education and surveillance in university hospital settings may be required. We suggest the use of evidence-based medicine in the treatment of CAP.

Background: The quality of life in patients with chronic obstructive pulmonary disease (COPD) is associated with poor pulmonary function, respiratory symptoms, incapacity to perform daily activities, as well as mental and cognitive disorders.Although there exists some evidence regarding the effect of socioeconomic status on the quality of life in the general population and those with chronic diseases, research is scarce on this issue in COPD patients. This study aimed to investigate the association between income and quality of life in COPD patients.Materials and Methods: In a case-control study, 131 subjects were selected through systematic sampling from all COPD patients admitted to the pulmonology Clinic of the Baqiyatallah Hospital during the year 2006. Subjects were then divided into three groups based on their household monthly income as follows: group I (n=52), income <2,000,000 Rials; group II (n=62), income between 2,000,000 and 3,000,000 Rials; and group III (n=17), income >3,000,000 Rials. The groups were matched with regard to gender, age, educational background, marital status, comorbidity burden, and insurance coverage. Spirometric measures and quality of life (SF-36) were compared between the groups.Results: The overall quality of life and physical health subscale were significantly different between the groups (p<0.05).Other parameters of SF-36 including physical functioning, role limitation due to physical problems, bodily pain, social functioning, general mental health, role limitation due to emotional problems, vitality, and mental health exhibited no significant difference between the groups (p>0.05).Conclusion: Quality of life and physical function of COPD patients are significantly correlated with their socioeconomic status. Future prospective studies are needed to find potential causative associations between the level of income and life quality in these patients.

Background: Fiberoptic bronchoscopy is a diagnostic method for respiratory diseases. At present, its diagnostic yield has been increased by different cytologic and histologic procedures by convention.Objective: This study was conducted to evaluate the concordance and agreement between cytologic and histologic findings in conventional diagnostic bronchoscopic methods (washing and biopsy) for lung malignancies.Materials and Methods: This was a cross-sectional study performed on 2076 cases of bronchial biopsy and bronchial washing between 1996 and 2003.Results: Of 2163 patients who underwent fiberoptic bronchoscopy after omitting 87(4%) cases due to unsatisfactory specimens, 2076 cases were studied including 832 (36.9%) females and 1244 (63.1%) males in the age range of 2 to 100 years, ( mean age 57.7±16.3 yrs). Male to female ratio was 1.5. Malignancy was diagnosed in 657(31.6%) biopsy and 283(13.6%) cytology specimens. Two hundred and sixty-five cases had malignant lesions according to both bronchial biopsy and bronchial washing; therefore, Kappa coefficient in both methods was 46.7% (P value = 0.000). Concordance rate was 77.4%. Ninety- seven point three percent of malignant cases were diagnosed by biopsy and 41.9% by cytology. Cytology contributed to an additional diagnostic rate of 2.6%.Conclusion: Kappa agreement is classified as fair and although there is a very good concordance between the two sampling techniques, the diagnostic yield of cytology for malignancy must be improved by combination of multiple assays.

Background: Serum C- Reactive Protein (CRP) is increased in patients with chronic obstructive pulmonary disease (COPD).It is used as a predictive factor for extra-pulmonary complications determining the prognosis of disease. It has not yet been defined whether this increase is due to the disease itself or is accompanied by ischemic heart disease and cigarette smoking.Thus, we decided to measure the serum CRP level in COPD patients without ischemic heart disease and also in healthy subjects by enzyme-linked immunosorbent assay (ELISA) and then we evaluated its relation with cigarette smoking, severity of dyspnea, exacerbation episodes, severity of disease and use of inhaled steroids.Materials and Methods: A comparative-descriptive study was performed on 45 stable COPD patients in 2006. All understudy patients were males.The exclusion criteria included ischemic heart disease and other causes of CRP increase. The control group consisted of 45 healthy men. The samples were selected consecutively. The serum CRP was measured by ELISA (high sensitive). Data were analyzed by SPSS software version 13.Results: Mann-Whitney test showed significant difference between serum CRP levels of COPD patients without ischemic heart disease (52.49 ng/ml) and healthy subjects (28.51 ng/ml) (p=0.01).There was a significant difference between the serum CRP level and the severity of dyspnea in COPD patients (p=0.04). No significant difference was detected between CRP level and the severity of disease, exacerbation episodes and use of inhaled steroids. Moreover, there was no significant difference between serum CRP and cigarette smoking in COPD patients and healthy subjects.Conclusion: The results showed that COPD itself can increase the serum CRP without ischemic heart disease and cigarette smoking. Since CRP is known as a systemic inflammatory marker and a major factor causing extrapulmonary complications, we hope this marker be applied for follow-up of patients, evaluation of treatment methods and their efficacy.

Background: Anesthesia is peri-operative medicine. The role of anesthesiologist in the quality of care rendered to patients during the pre-operative period is well known. The role of pre-operative anesthesia clinics in providing better conditions for patients undergoing anesthesia is now well documented. This study was performed to evaluate the familiarity of Iranian patients with the aims of anesthesia clinics 10 years after the establishment of such clinics in Iran.Materials and Methods: All patients referred to anesthesia clinics in two university medical centers were evaluated during a 2-week period. A questionnaire was given to them and answers were analyzed and interpreted by statistical methods.Results: Of the 286 patients, who participated in this study, 56% were males and 44% were females; 43% of them were familiar with the goals of pre-op anesthesia, 83% of the patients mentioned that pre-op evaluation was the reason of their referral and 67% gave a positive feed-back on the clinic.The need for creating more motivation in patients and physicians was mentioned by 83% of the patients.Conclusion: Considering the statistical results, it seems that there is a great need to familiarize patients with the goals of these clinics and to create some motivation in them. By doing so, we can hope to offer better services to patients and reduce the anesthesia complications and anxiety.

Background: Six to eight million people are infected with tuberculosis (TB) annually throughout the world, out of which 2 to 3 million die. BCG vaccination and its efficacy are always used in tuberculosis control planning. There are different rates of BCG vaccination efficacy in the world from 0 to 80%. BCG vaccine has different efficacy in endemic and non-endemic areas.The prevalence of tuberculosis in Iran is high; therefore it was necessary to perform a study in this regard.Materials and Methods: This was a case-control descriptive study conducted from 2001- 2003. There were 50 cases of active pulmonary tuberculosis (according to WHO definitions), and 100 controls without tuberculosis admitted for other reasons.Results: Vaccination was done in 10 (20%) people in the case group and 36 (36%) people in the control group (OR: 43%).Thus vaccine efficacy was calculated to be 57% in this study from the equation VE=1- OR (CI: 95% between 0.04-0.81).Twenty percent of vaccinated people have been protected from active tuberculosis in this study.Conclusion: In this study vaccine efficacy was 57% (CI: 95% between 4-81%), and protection rate of vaccinated people against active tuberculosis was 20%. The effectiveness of BCG vaccine is not constant in all situations and old age and past history of contact with TB patients are confounding factors causing the low efficacy of the vaccine. While case control studieshave limitations; thus, similar studies should be planned in different parts of our country for more accurate results.

Multiple myeloma (MM) is a common hematologic malignancy. Pleural effusion is a rare presenting feature of multiple myeloma which carries a poor prognosis. Few cases of multiple myeloma with pleural involvement have been reported in the medical literature. We report a patient with MM diagnosed by cytologic examination of pleural fluid. Our patient was a 64- year old man with multiple myeloma who was receiving chemotherapy. He had developed dry coughs and exertional dyspnea about a month prior to the admission. Radiographic examination showed left pleural effusion with mediastinal shift to the opposite side. Diagnostic thoracentesis of pleural fluid was performed for the patient. Pathologic examination of pleural fluid showed plasmocytes and plasmablast type mononuclear cells with atypical nuclei, consistent with the diagnosis of pleural effusion due to multiple myeloma. In view of multiple etiologies of pleural effusion in malignant diseases, rare etiologies should also be considered in order to treat the effusion appropriately.

The control and reduction of silica dust exposure in developed countries have resulted in a remarkable decrease in morbidity and mortality due to silicosis but exposure risks have remained high in other countries. Here, we present a fatal case of silicosis in a 27 year-old man with exposure duration of less than one year. This case indicated that intense exposure to silica dust can cause significant fibrotic disease after a short latency period.

Traumatic myocardial injury occurs in up to 55% of patients sustaining blunt chest trauma. We report two cases of myocardial infarction following blunt chest trauma in two young men due to a car accident. They were both suffering multiple traumas and were hospitalized in ICU. Diagnostic and therapeutic procedures performed for these patients are presented in this article.

The field of thoracic surgery is a postgraduate sub-specialty of general surgery and has developed considerably in Iran during the recent decades. Nowadays, thoracic surgery procedures are performed by specialists who have been trained specifically in this field and the quality of care given is in line with international standards. This paper addresses the history of thoracic surgery in Iran.Data were collected through interview of professors, review of archives and personal albums and data present in the council of medical education. Almost 80 years ago, general surgeons used to perform thoracic surgical procedures. But closed-circuit anesthesia was not prevalent in Iran until 1940 and there was no training available in the country for thoracic surgeons. Antibiotics were not available and surgeons were not acquainted with new methods to evacuate the pleural space (chest tube and under water seal drainage). The only procedures performed were limited to management of emergencies, trauma and abscess drainage. Surgical intervention for treatment of tuberculosis in some patients was one of the factors responsible for development of this field of surgery.General surgeons trained abroad that came back to Iran were familiar with the principles of thoracic surgery and would perform it. In some army medical centers and some centers affiliated to foreign countries, thoracic surgeries were performed by Iranian or foreign physicians.Professor Yahya Adl used to perform thoracic surgeries and taught it to his residents. In 1951, Dr. Sadegh Ghazi and shortly after, Dr. Anwar Shakki started operations in Bou-Ali and Abo-Hossein Hospitals at the request of the TB charity foundation. They were the pioneers who started to perform TB, lung and thoracic surgeries. They were educated in France. The period of 1951-1961 can be considered as the initiation period of thoracic surgery as a subspecialty in Iran. Afterwards, this field was extended to the Masih Daneshvari, Sorkheh Hesar and army medical centers. In early 1950, cardiac and vascular surgeon graduates from the USA and other countries who had returned home established the field of thoracic surgery at Tehran University and other universities. Thus, official training in this field was started. In 1984, thoracic surgery became a postgraduate sub- specialty field approved by the medical education council. Thus far, over 80 physicians have graduated in this field most of which are working in academic fields throughout the country. Tehran, Shaheed Beheshti and Tabriz Universities of Medical Sciences have departments approved for training thoracic surgery fellows. In many universities and several medical centers, trained surgeons have established thoracic surgery wards and are working in this field.

WHAT IS YOUR DIAGNOSIS?A 30-year-old Iranian man was admitted to our hospital due to productive cough, chest pain, sweating and 14 Kg weight loss since three months ago. He developed fever and progressive dyspnea seven days ago.The patient was a painter, 16 pack/year smoker, oral opium addict, with a history of incarceration. But he denied intravenous drug abuse. He was single and had not any sexual contact. He had a history of pulmonary tuberculosis seven years ago with complete cure after treatment for nine months.In physical examination, he was cachectic with severe respiratory distress, unable to walk. The vital signs were: oral temperature: 39 0C; pulse rate: 108 / min; respiratory rate: 28/min and blood pressure: 120/80 mmHg. Oxygen saturation rate was 73% with ambient air. Heart sounds were normal. Fine crackles were heard in both lungs .Peripheral cyanosis was present and a tattoo was seen on his right hand. There was no further abnormal clinical finding.The results of the laboratory tests were: total leukocyte count: 6900 cell /ml with 82% neutrophils, 6% band cells and 12% lymphocytes, hemoglobin: 13.1 gr/dl, platelet: 280000 cell /ml; normal liver function tests, biochemistry and electrolytes.Chest X- ray (Figure 1) and high resolution lung CT Scan (HRCT) were obtained (Figure 2).Bronchoscopy, bronchoalveolar lavage and transbronchial lung biopsies were performed.

Chest X-ray demonstrated bilateral fluffy alveolar densities in midzone of the lungs and parahilar peribronchial infiltrations were also seen.High resolution computed tomography (HRCT) of the lung revealed bilateral nonhomogeneous ground glass opacities in mid and upper zones of the lungs.Mild bilateral peribronchial wall thickening was also seen. These findings were suggestive of Pneumocystis Jirovecii Pneumonia.Smear of bronchoalveolar lavage (BAL) for pneumocystis was suspicious. Transbronchial biopsy revealed mild distortion of alveolar architecture and prominent intra-alveolar deposition of foamy eosinophilic exudates. Immuno-histochemistry staining with monoclonal antibody was strongly positive for Pneumocystis.