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   Table of Contents - Current issue
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July-September 2019
Volume 13 | Issue 3
Page Nos. 289-442

Online since Friday, July 26, 2019

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ORIGINAL ARTICLES - AIRWAY DISEASES  

B-type natriuretic peptide as a predictor of severity in admitted patients with acute exacerbation of COPD p. 289
Nasser K Abdelnaby, Hassan A Shabana, Waleed R Arafat
DOI:10.4103/ejb.ejb_90_18  
Background patients with acute AECOPD show an abrupt worsening of baseline ventricular function and pulmonary hypertension, using clear predictors or markers for severity in such patients is critical to be early stratified and properly managed. Aim Assess the value of BNP as A predictor for severity in patients with AECOPD represented by need for intensive care admission, invasive and non-invasive mechanical ventilation, pulmonary hypertension, hospital and 3 months mortality. Study design Prospective study Methods A prospective Cohort study in tertiary level hospital conducted on 88 patients with AECOPD and 88 healthy control subjects, patients were divided into 2 subgroups: ICU admitted and ward admitted Patient were subjected to clinical, electrocardiographic, radiological and laboratory evaluation and observation of the clinical course during admission and 3 months following hospital discharge. Results The study revealed higher BNP in AECOPD patients compared with healthy control subjects and in ICU admitted compared with ward patients (P, 0.001). positive correlation with age, smoking index, Paco2, SPAP, RVD, need for ICU ,IMV, hospital stay and overall Mortality (r.coefficient: 0.398, 0.533, 0.605, 0.635, 0.732, -0.617, 0.577, 0.728 0.030, respectivly) ,we revealed negative correlation with ABGs parameters (Pao2, PH and o2 saturation), with r. coefficient of (-0.616, -0.609, -0.630, respectively), linear regression revelled that BNP is significant predictors for ICU admission ,ROC curve revealed that BNP more than 425pg/ml had sensitivity , specificity of (70.8% and, 100%) to predict need for ICU admission. Conclusion BNP may be considered as an accessible, useful, non-invasive and low-cost marker of severity COPD exacerbations.
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Comparing frequencies of asthma-chronic obstructive pulmonary disease overlap in patients with stable chronic obstructive pulmonary disease p. 298
Nezar R Mohamed, Mohamed A.E Abd El Hakim, Zainab H Saeed, Rofaida N.E Helmy
DOI:10.4103/ejb.ejb_1_19  
Context Asthma and chronic obstructive pulmonary disease (COPD) may share some physiological features and coexist as asthma-chronic obstructive pulmonary disease overlap (ACO). The prevalence of ACO differs according to the diagnostic criteria and study design. In patients with COPD, the prevalence of ACO varies from 5 to 55%. This study aims to examine the effect of using different diagnostic criteria on the resulting frequency of ACO in patients with COPD. Settings and design This cross-sectional observational study enrolled 60 patients with COPD randomly selected from outpatient clinics of Chest Department of Minia Cardio-Thoracic University Hospital during the period from September 2015 to September 2016. Patients and methods History, clinical examination, spirometry, and sputum cytology were done. The frequency of ACO among the 60 patients with stable COPD was separately studied based on five different diagnostic criteria (Hardin’s, Menezes, combined Hardin and Menezes, Spanish consensus, and Global Initiative for Asthma-Global Initiative for Chronic Obstructive Lung Disease criteria). Statistical analysis Statistical analysis was performed using statistical package for social science software (χ2 test and independent sample t test). Results The frequency of ACO in COPD was 40, 23.3, 16.7, 13.3, and 10% on applying combined Hardin and Menezes, Hardin’s alone, Menezes alone, the Spanish consensus, and Global Initiative for Asthma-Global Initiative for Chronic Obstructive Lung Disease criteria, respectively. Conclusion The frequency of ACO in patients with COPD decreases when using more restrictive diagnostic criteria.
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Transthoracic ultrasound in the diagnosis of bronchiectasis: is it valuable? p. 303
Mohamed Fawzy Abdel Ghany
DOI:10.4103/ejb.ejb_2_19  
Objectives The purposeof this study was to evaluate the diagnostic accuracy of transthoracic ultrasound in patients with bronchiectasis and compare it with high-resolution computed tomography (HRCT) chest. Patients and methods Sixty-one patients with bronchiectasis underwent transthoracic ultrasound. Radiological severity of bronchiectasis was assessed using a modified Reiff score (number of lobes involved in six lobes multiplied by the degree of bronchial dilatation) (tubular=1, varicose=2, cystic=3). Transthoracic findings were compared with that of the HRCT and pulmonary function tests. Results Two patterns of sonographic abnormalities were detected: B-line pattern and c-profile (consolidation) pattern. The first was detected in 42 (68.8%) patients and the later was detected in seven (11.1%) patients. Twelve (19.7%) patients had normal sonographic examination. There was significant positive correlation between severity of bronchiectasis by the modified Reiff score pattern. The highest score correlated with the c-profile pattern and the lower score correlated with the B-line pattern (P≤0.001), while patients with very low score (≤20) had normal examination. There was a negative correlation between HRCT score, ultrasound pattern, and Partial pressure of oxygen tension (PO2) (P≤0.001). Conclusion Bronchiectasis can be assessed by chest ultrasound; pattern of sonography is correlated to the radiological severity and functional impairment of the disease.
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ORIGINAL ARTICLES: BRONCHOSOCOPY & INTERVENTIONAL PULMONOLOGY Top

Implementation of bronchoscopic conventional transbronchial needle aspiration service in a tertiary care chest hospital p. 309
Mohammed A Farrag, Gehan M El Assal, Ashraf M Madkour, Nehad M Osman, Manar H Taha
DOI:10.4103/ejb.ejb_95_18  
Background Conventional transbronchial needle aspiration (C-TBNA) is a unique technique that allows the sampling tissue from beyond the endobronchial tree, such as enlarged lymph nodes, peribronchial, or submucosal lesions. However, it remains underutilized and even unavailable in many countries and centers around the world including Egypt. Objective This study aimed to implement bronchoscopic C-TBNA service in a tertiary care chest hospital with special emphasis on the diagnostic yield, complications encountered, and learning experience. Patients and methods This cohort study was conducted on 60 patients with bronchoscopic nonvisible extraluminal lesions who have sought bronchoscopic C-TBNA service at the Bronchoscopy Unit of both Ain Shams University Hospital and Giza Chest Hospital during the period from June 2016 to February 2018. Results The overall C-TBNA had a diagnostic yield of 88.3% in which 68.3% were malignant and 20% had sarcoidosis without serious complications recorded except for minor non-life-threatening bleeding in 21.7% of cases. After 6 months of C-TBNA learning experience, the diagnostic yield showed improvement in physicians without previous C-TBNA experience, but without reaching a statistical significance. Also, there were significant reduction in both duration and complications of C-TBNA. Conclusion Implementing C-TBNA service in a tertiary care chest hospital in bronchoscopically nonvisible extraluminal lesions seems to be a safe, easy technique with high diagnostic yield and its learning performance was able to be improved over time.
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Endoscopic transbronchial needle aspiration in sampling mediastinal lesions Highly accessed article p. 314
Mohammed A Ibrahim, Aida M Yousef, Mohamed S. Abdelrahman Hantera, Magda Abdelsalam Ahmed, Sayed A.M Abdelhafez
DOI:10.4103/ejb.ejb_96_18  
Context Endoscopy plays an integral part in the evaluation of mediastinum. Transbronchial sampling can be done conventionally or guided with endobronchial ultrasonography (EBUS), which is a new tool that allows seeing beyond the airway. Following its invention, the use of conventional sampling has declined. Aims To evaluate the efficacy of EBUS-transbronchial needle aspiration (TBNA) in sampling mediastinal lesions after conventionally negative TBNA result and to compare EBUS-TBNA sampling in subcarinal and hilar sites versus paratracheal sites regarding diagnostic yield. Settings and design A prospective evaluation study was done. Patients and methods The study enrolled 52 patients with undiagnosed mediastinal lymphadenopathy or lesions. Subcarinal lesions were sampled by both conventional TBNA and EBUS-TBNA sampling (after negative conventional sampling results), and paratracheal lesions were sampled only with EBUS. Statistical analysis used Data were analyzed to test statistical significant difference between groups. Quantitative data were presented as mean±SD, and Student t test was used to compare between two groups. Results No complications were reported. Conventional subcarinal TBNA sampling was done in 37 cases, where sufficient sampling was seen in 67.6% of cases, was diagnostic in 16.2% and had sensitivity of 20%. EBUS-TBNA was done in 22 cases after negative conventional sampling result, and in additional 15 cases as an initial procedure during the study. EBUS diagnosed 89.2% of cases, with sensitivity of 97.1%. Diagnostic percent in EBUS targeting subcarinal/hilar sites was 81.8% whereas was 100% in paratracheal EBUS sampling. Conclusion Both modalities of sampling are safe. Diagnostic value of EBUS-TBNA exceeded much more than conventional sampling.
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ORIGINAL ARTICLES: CRITICAL CARES Top

The value of chest ultrasonography applications in the respiratory ICU p. 323
Medhat F Negm, Mohammad H Kamel, Osama I Mohammad, Rehab E Elsawy, Hamada M Khater
DOI:10.4103/ejb.ejb_78_18  
Background Diverse imaging systems can be utilized for the evaluation of chest issues in ICU patients; ultrasound (US) is a decent analytic instrument without exposing the patients to radiation and risk of transfer. Objectives To compare the diagnostic performance of transthoracic US and bedside chest radiography (CXR) for the detection of various pathological abnormalities in fundamentally sick patients, using chest computed tomography as a gold standard. Patients and methods Two hundred and fifty-six patients who were admitted in the Respiratory Care Unit were included in this study. CXR, computed tomography, and transthoracic US were done to all the patients. Six pathological entities were evaluated: pleural effusion, pneumothorax, consolidation, interstitial lung diseases, pulmonary embolism, and neoplasms. Results All patients were evaluated by the three imaging techniques. The sensitivity and specificity of CXR were 42.1, 84.4% for pneumonia 50.0, 90.0% for pleural effusion, 45.5, 90.6% for interstitial syndrome, 50.0, 94.8% for pneumothorax, 60, 100% for pulmonary embolism, and 66, 94% for neoplasm, while the values for chest US were 89.47, 100% for pneumonia, 60, 100% for pulmonary embolism, 100, 100% for pleural effusion, pneumothorax, interstitial syndrome, and neoplasm. Conclusion US examination of the chest is a noninvasive and promising bedside tool in the evaluation of patients in the Respiratory Care Unit.
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Effects of sedation on clinical, gasometric, and respiratory muscle parameters in critically ill chronic obstructive pulmonary disease patients p. 328
Atef F Alkarn, Mohamed F Abdelghany, Mohammad G.A Khalaf, Emad Z Kamel, Wafaa A.H Gadalla
DOI:10.4103/ejb.ejb_79_18  
Background Severe chronic obstructive pulmonary disease (COPD) exacerbation requiring mechanical ventilation is commonly encountered in the ICU. Sedation is necessary to facilitate mechanical ventilation. The effect of no-sedation strategy on different patient parameters on the ventilator has not yet been well studied. The aim of this study was to test the efficacy of no-sedation protocol in controlling COPD patient’s gasometric and clinical parameters during mechanical ventilation. Patients and methods Patients with COPD who required mechanical ventilation were randomized to either: sedated with daily interruption (control group) (n=50) or nonsedated group (n=47). The change in the partial pressure of arterial CO2 (PaCO2) was the primary outcome measure. Secondary outcome measures included: changes in pH, heart rate (HR), mean arterial blood pressure (MAP), respiratory rate, airway occlusion pressure (P0.1), and negative inspiratory force (NIF). Recordings for arterial blood gases, HR, MAP, and respiratory rate were performed as baseline at intubation, 1, 2, 12, 24, and 48 h after intubation. NIF and P0.1 were recorded 48 h after intubation. Results No significant difference was found in baseline recordings of PaCO2, pH, HR, MAP, and respiratory rate between the sedated and nonsedated groups. Further recordings of PaCO2 (P_1, P_2, P_3, and P_4<0.001, P_5=0.005), HR (P<0.001), and respiratory rate (P<0.001) were significantly higher in the nonsedated group. The rate of correction of pH from acidosis was faster among the sedated patients. MAP was significantly higher in nonsedated patients in recordings 2, 12, and 48 h after intubation (P_1=0.9, P_2<0.001, P_3<0.001, P_4=0.87, P_5<0.001). No significant difference was found in NIF or P0.1 between the two groups (P=0.8 and 0.1, respectively). Conclusion COPD patients managed by no-sedation strategy had higher PaCO2, HR, MAP, and respiratory rate. No-sedation had no significant effect on respiratory muscle function when compared with daily interruption of sedation.
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Predictors of spontaneous breathing outcome in mechanically ventilated chronic obstructive pulmonary disease patients p. 335
Suzan S Sayed, Aliae A Mohammed Hussein, Waleed G Elddin Khaleel
DOI:10.4103/ejb.ejb_81_18  
Background Morbidity and mortality due to chronic obstructive pulmonary disease (COPD) represents a worldwide pandemic, with exacerbations necessitating mechanical ventilation representing important aspects of disease management. Attempts to search for better weaning indices (WIs) is a continuous process. This study seeks for best index predicting weaning outcome in COPD patients. Patients and methods 2One hundred and fifty COPD patients (110 men, 40 women) receiving mechanical ventilation were included in this study. Weaning process as early as possible was considered. Patients who were receiving mechanical ventilation of more than 24 h underwent daily screen of subjective and objective indices for weaning readiness. Measurements done on admission and through weaning process included: acute physiology and chronic health evaluation II score, simplified acute physiology score II, CORE (compliance, oxygenation, respiration, and effort) index, rapid shallow breathing index (RSBI), WI, integrative weaning index (IWI), compliance, rate, oxygenation, and pressure (CROP) index and P0.1/negative inspiratory force index. Results There is a highly significant difference between weaning success and failure groups regarding the CORE index, RSBI, WI, IWI, CROP index, and P0.1/negative inspiratory force. CORE index had the highest area under the curve (0.929) which was significantly higher than other indices included in the study. Conclusion RSBI, WI, IWI, and CROP index displayed moderate accuracy in predicting spontaneous breathing trial success in COPD patients. CORE index showed better diagnostic performance in predicting successful weaning and had the highest accuracy.
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Bacteriological profile of critically ill patients with chronic obstructive pulmonary disease in respiratory intensive care unit in Assuit University Hospital p. 343
Maha K Ghanem, Hoda A Makhlouf, Ali A Hasan, Heba G Rashed, Hadeer S Khalifa
DOI:10.4103/ejb.ejb_83_18  
Background Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is responsible for a high proportion of morbidity and antibiotic use. This study aimed to identify the causative bacteria, antimicrobial sensitivity, and resistance of hospitalized patients in respiratory ICU owing to AECOPD. Patients and methods This prospective study was performed at Assiut University Hospitals on 50 patients with AECOPD who needed ICU admission. Samples included sputum for staining and culture. Samples were cultured on two bacteriological media (blood and MacConkey’s agars) to detect gram-positive and gram-negative organisms and their sensitivity to different antibiotics. Results Klebsiella pneumoniae was the most frequently detected organism in 29 (58%) patients followed by Pseudomonas aeruginosa in 14 (28%) patients, methicillin resistant Staphylococcus aureus (MRSA) in eight (16%) patients, Acinetobacter baumannii in seven (14%) patients, Proteus spp. and Staphylococcus aureus in five (10%) patients each, and Escherichia coli in three (6%) patients. No growth was reported in three (6%) patients. Among gram-positive organisms, linezolid had the upper hand of efficacy followed by vancomycin and teicoplanin. Gram-negative organisms had high rate or resistance to most tested antibiotics. Frequency of death was more (62.5%) in patients with MRSA. Conclusion K. pneumoniae was the most frequent organism followed by P. aeruginosa, MRSA, and A. baumannii. The isolated bacterial strains were characterized by high resistance rates to the most used antimicrobials. Mortality rate was more among patients with MRSA.
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ORIGINAL ARTICLES: DIFFUSE PARENCHYMAL LUNG DISEASES Top

Role of telomerase expression in interstitial lung diseases p. 349
Marwa M Shaban, Radwa A Elhefny, Sabah H Hussein, Amul A Badr, Zeinab A Nour
DOI:10.4103/ejb.ejb_71_18  
Background Telomeres are hexameric nucleotide sequences. The biological role of telomeres is to prevent shortening of DNA to preserve integrity of the genome. Length of telomeres is determined by age, sex, and environmental exposures. Telomeres are vulnerable to injury by oxidative stress. Telomere length is sustained by telomerase, a ribonucleoprotein telomerase reverse transcriptase (TERT). Telomerase may help cell growth and secure against cell death. ‘Telomeropathy’ is associated with genetic mutations. The most common phenotype related to telomerase mutation is pulmonary fibrosis. Objective To investigate the associations of both TERT and telomerase RNA component C with disease progression in patients with interstitial lung diseases (ILDs), which include idiopathic pulmonary fibrosis (IPF), and to compare results between patients with ILD and control. Patients and methods A total of 46 patients with different types of ILDs were enrolled as well as 15 healthy persons as control. Whole blood sample was obtained from both patients and healthy control for detection of expression of telomerase gene by quantitative real-time PCR. Results There was a significant negative correlation between telomerase reverse transcriptase (h-TERT) and partial pressure of oxygen (r=−23, P=0.03). Both h-TERT and telomerase reverse transcriptaseRNA component (h-TERC) were relatively more expressed in patients with IPF with pulmonary hypertension, whereas there was a significant elevation of h-TERT relative expression in patients with IPF with honeycombing high-resolution computed tomography pattern in comparison with those with reticulonodular pattern, with median of 0.85 versus 0.29, respectively. Conclusion Hypoxia may affect DNA damage in the telomere region. Expression of telomerase may take part in pulmonary fibrosis. Exposure to hypoxia or growth factors can stimulate the expression of telomerase on cells of vascular smooth muscle.
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Evaluation of sexual function and depression in married women with interstitial lung diseases p. 358
Doaa M Magdy, Ahmed Metwally, Randa A El Zohne
DOI:10.4103/ejb.ejb_91_18  
Background Little is known about female sexual function and interstitial lung disease (ILD). The purpose of this study was to evaluate sexual function and depression in married women with ILD. Patients and methods Of the 65 participants enrolled, 45 patients with ILD fulfilled the inclusion criteria, comprising 12 patients with idiopathic pulmonary fibrosis, 25 with connective tissue disease-associated interstitial pneumonias, eight patients with other interstitial pneumonias. Moreover, 20 age-matched normal individuals were recruited as controls. All participants were evaluated for clinical data, including age, BMI, comorbidities, duration of ILD, usage of glucocorticoids (dose and duration), and number of exacerbation within the past year. All women fulfilled the female sexual function index (FSFI) and Beck depression inventory. Results The mean age of the ILD group was 40.4±8.9 years. Overall, 33.3% were hypertensive and 53.3% had pulmonary hypertension, whereas diabetes mellitus and dyslipidemia were found in 26.6 and 15.5%, respectively. The mean duration since diagnosis of ILD and using glucocorticoids was 8.46±2.77 and 9.23±2.31 years. No differences in forced vital capacity and forced expiratory volume in 1 s were observed. There was a significant decrease in mean diffusion capacity (diffusion lung capacity for carbon monoxide) (61.8±7.10 vs. 68.7±6.86%) when compared with control (P=0.000*). Using FSFI, there was a significant decrease in global FSFI score and each domain in patients with ILD as compared with control (P=0.000*). The overall prevalence of depression was 80%. Correlation was found between total FSFI and disease duration, duration of glucocorticoids and dosage (≥20 mg), and depression (Beck depression inventory). Conclusion Despite mild impairment in pulmonary function, female patients with ILD have reported sexual dysfunction and increased depression. Thus, physicians should be reminded that patients with ILD need a comprehensive evaluation for sexual function.
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A rare entity of interstitial lung disease, pleuropulmonary fibroelastosis: does it affect the chest wall geometry? p. 363
Yosri M.K Akl, Mohamed S Ismail, Yasmine H El-Hinnawy, Shady N Mashhour
DOI:10.4103/ejb.ejb_94_18  
Introduction Pleuropulmonary fibroelastosis (PPFE) is a rare type of interstitial lung disease (ILD); however, it may not be as rare as it was described. PPFE has been recognized increasingly worldwide during the past years. Patients and methods The study was held in the Chest Department, Kasr Al-Ainy hospitals, during the period from January 2015 till June 2018. Seventy patients were included and divided into two main groups. Group 1 included 36 cases with PPFE, diagnosed either radiologically alone or combined with histopathological examination of lung biopsy. Group 2 included 34 cases of hypersensitivity pneumonitis (HP) as controls. Group 1 was further subdivided into two subgroups: group A included patients with 19 PPFE without any other pattern of ILD, and group B included 17 cases of PPFE associated with other forms of ILD. Clinical assessment, BMI, and high-resolution computed tomography chest were done. The inner anteroposterior diameter (APD) and transverse diameter (TD) of the chest wall were measured, and the ratio between them was calculated. Results Significant female predominance was observed. Both groups of PPFE presented at earlier age than the HP group. Patients with PPFE had a lower body weight and BMI than HP group. There was a significant reduction in the APD and TD in both groups of PPFE than HP group. Conclusion Thirty-six cases with PPFE presented either alone or in association with other forms of ILD. Significant reduction in their chest wall APD in comparison with TD was observed, giving a characteristic flat shape of the chest. Further evaluation of this phenomena and its explanation is required.
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ORIGINAL ARTICLE: MISCELLANEOUS Top

Mediastinal lesions, spectrum, and modalities of diagnosis: a retrospective multicenter-based experience p. 370
Mohamed S.Abdelrahman Hantera, Hamed A.H Abdalla, Mohammed A Ibrahim
DOI:10.4103/ejb.ejb_39_19  
Context Diagnosis of mediastinal lesions start with clinical evaluation combined with specific /boratory investigation and different imaging modalities till biopsy that can obtained by percutaneous approach, endoscopic approach, or finally open approach. Aims A retrospective assessment of different mediastinal lesions was performed of the diagnosis and the different modalities of sampling used in three different Egyptian centers (Cairo, Mansoura, and Tanta universities) during the period 2017–2018. Settings and design This was a retrospective study. Patients and methods Study enrolled 92 patients with mediastinal lesions, collected from medical records of the three chest department during the period 2017–2018, were retrospectively analyzed. Data included clinical presentation, diagnostic methods, and diagnostic outcome. Results Mediastinal lymphadenopathies were the most common lesions. Endobronchial ultrasound was the sampling modality most used successfully (39.13%) to achieve the final diagnosis, followed by computed tomography-guided trucut biopsy (25%). The most frequent pathological finding was lymphomas, 34.78%, followed by adenocarcinomas, 26%. Conclusion Malignancy was the commonest diagnosis among cases enrolled in our study.
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ORIGINAL ARTICLES: PLEURAL DISEASES Top

Evaluation of rapid pleurodesis technique in patients with malignant pleural effusion p. 377
Muhammed A Farrag, Haytham S Diab, Muhammed R. Abd Al Aziz Taha
DOI:10.4103/ejb.ejb_102_17  
Background The objective of this study is to see whether a rapid method of pleurodesis is superior to the standard protocol in patients with symptomatic malignant pleural effusion. Patients and methods This is a prospective, randomized control study that was held in Ain-Shams University Hospitals and included 30 patients diagnosed with malignant pleural effusion. Thirty patients who had been diagnosed with malignant pleural effusion histologically and/or cytologically were assessed and they were divided into two groups. Group A: 10 patients submitted to the standard pleurodesis technique using 24 or 28 F thoracotomy tube. Group B: 20 patients submitted to the rapid pleurodesis technique using pigtail (12 F). Pleurodesis was done by vibramycin and follow up of the patients was done with chest radiography at 1, 3, and 6 months after pleurodesis. Results There was no statistically significant difference in the demographic features, site of the primary tumor, disease characteristics, and response rates in any evaluation period in both groups. However, the number of days of drainage and hospitalization were significantly lower in the second group. Conclusion This new pleurodesis method provided a shorter hospital stay resulting in superior cost-effectiveness and palliation without sacrificing the efficacy of pleurodesis.
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Diagnostic value of calprotectin in differentiation between benign and malignant pleural effusion p. 382
Omar M Mohammed, Kamel M Hussein, Abdelgawad E Ramadan, Gouda T Mahmoud, Marwa El-Sayed El-Naggar, Nor Eldein Z Gaber
DOI:10.4103/ejb.ejb_77_18  
Background Pleural effusion can arise as a result of more than 50 recognized causes and the differentiation between benign and malignant origin of the fluid is still a diagnostic challenge. The ability of tumor markers and other biological markers to make better diagnosis of malignant pleural effusion (MPE) remains questionable. Out of these, the calcium-related proteins S100-A8 and S100-A9 (the noncovalent heterodimer calprotectin) were demonstrated in a small amount in malignant not in benign pleural effusion. Objectives This research aimed to assess the diagnostic value of calprotectin in the differentiation between infectious or benign and MPE. Patients and methods Sixty patients were divided into group I: malignant and group II: infectious pleural effusions (which were further divided into group IIA: parapneumonic effusion and group IIB: tuberculous effusion) Quantitative measurement of calprotectin was done using the enzyme-linked immunosorbent assay technique in pleural effusion. Results Pleural calprotectin level in MPEs (229.2±168.6 ng/ml) was significantly lower than its level of infectious pleural effusions (3202.2±1304.8 ng/ml; P<0.001). The cutoff value of calprotectin level for the diagnosis of MPE was less than or equal to 730.5 ng/ml, with 95% confidence interval and the area under the curve was 0.999, the corresponding sensitivity was 96.7 and the specificity was 100% (P<0.001). Conclusion Calprotectin is a valuable biomarker in differentiating malignant from infectious pleural effusion.
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Comparison of methods to quantitate spontaneous pneumothorax - A study from a tertiary care hospital p. 388
Uma Devaraj, Priya Ramachandran, UmaMaheswari Krishnaswamy, Namita Sinha, George D’Souza
DOI:10.4103/ejb.ejb_93_18  
Background Pneumothorax can present as a respiratory emergency and has varied etiology. However, literature available on assessment and management of primary spontaneous pneumothorax (PSP) based on radiological quantitation is scarce. This study was undertaken to compare two different methods of quantitating pneumothorax size with that recommended in American Thoracic Society (ATS) guideline on chest radiogram with respect to possible change in management practices. Patients and methods A prospective cohort of adults presenting with spontaneous pneumothorax (SP) over 3 years to Emergency and Pulmonology Department, St John’s Medical College Hospital, Bangalore, was included. Demographic characteristics and clinical presentation were compiled. Management of SP was based on ATS guidelines. PSP size on chest radiogram was requantitated in the included patients using Light’s index and Collin’s method and was compared with that proposed by the ATS guideline. Results Seventy-six participants with SP were studied; their mean age was 43.7 years, with a preponderance of male patients (84.2%). Twenty-four (31.6%) patients had PSP and 52 (68.4%) patients had secondary spontaneous pneumothorax. In PSP, there was poor agreement between various methods of estimating size of pneumothorax on chest radiogram (Kappa statistic=0.23; ICC of 0.263). Three (12.5%) of the 24 incidences of PSP, which were treated conservatively as per ATS guidelines, would have required invasive intervention if Light’s index or the Collin’s formula were taken into consideration. Conclusion There was poor agreement of radiological pneumothorax size estimation by Collin’s, Light’s, and that proposed in the ATS guidelines. Thus, a unified, standardized method of radiological assessment of PSP is required.
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ORIGINAL ARTICLES - PULMONARY INFECTIONS Top

Easy and rapid diagnosis of Mycoplasma pneumonia: is it possible? p. 394
Reham M Elkolaly, Maii A Shams Eldeen
DOI:10.4103/ejb.ejb_46_18  
Background Atypical pneumonia (AP) with its different pathogens comprises a reasonable ratio of community-acquired pneumonia. Mycoplasma pneumoniae (M. pneumoniae) constitutes a known pathogen causing AP with pulmonary and extrapulmonary symptoms that necessitate early diagnosis and treatment. Serology and culture give diagnosis but after few days of infection onset. Aim Study the incidence of M. pneumonia using PCR and relation to clinical symptoms. Settings and design Comprehensive, prospective study. Materials and methods A total of 80 patients with suspected AP were examined for clinical symptoms and signs such as cough, crepitations, arrhythmia and conscious level, and sputum was investigated using PCR for M. pneumoniae. Those with dry cough were subjected to fiberoptic-bronchoscopic bronchoalveolar lavage and the fluid was examined by PCR. Statistical analysis Data were analyzed with the SPSS 22 software package. Results Using the PCR method; M. pneumonia was 42%, mostly by bronchoscopic lavage because of dry cough, with significant correlation to arrhythmia, disturbed consciousness, and positive radiologic infiltrations (74, 65,76%, respectively). Conclusion PCR is considered a highly specific diagnostic method for M. pneumonia. AP incidence is high in our region with special consideration to M. pneumonia as a causative agent with high percentage.
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Valuing the use of GeneXpert test as an unconventional approach to diagnose pulmonary tuberculosis p. 403
Amany Omar, Abd-Elazim Abo Elfadl, Yousef Ahmed, Moustafa Hosny
DOI:10.4103/ejb.ejb_88_18  
Background A rapid, highly sensitive, and qualitative diagnostic test will significantly reduce the incidence of tuberculosis (TB). GeneXpert test is the test that is supposed to play this role with those specifications. Objective Our goal was to assess the precision of the GeneXpert test in the diagnosis of pulmonary TB. Patients and methods This cross-sectional analytic study was carried out at Assiut University Hospital in collaboration with Assiut Chest Hospital, Assiut, Egypt. A total of 67 patients of suspected pulmonary TB were included. For microbiological examination, two sputum samples were obtained from each patient within the same day. One sample was collected at Assiut University Hospital and subjected to smear microscopy by Ziehl–Neelsen staining and culture on Lowenstein–Jensen media. The other sample was taken at Assiut Chest Hospital to be processed for GeneXpert Mycobacterium tuberculosis/rifampicin assay. The culture was applied as a confirmatory test to evaluate the Xpert Mycobacterium tuberculosis/rifampicin assay test. Results GeneXpert had 95.9% sensitivity and 94.4% specificity in diagnosing pulmonary TB with the area under the curve of 0.95 and overall diagnostic accuracy of 95.5%. Ziehl–Neelsen examination had 65.3% sensitivity and 100% specificity with the area under the curve of 0.83 and overall diagnostic accuracy of 74.6. For smear-negative, culture-positive cases, GeneXpert showed sensitivity of 94.1%. False-positive GeneXpert for TB was recorded in just one patient. Conclusion The GeneXpert test is accurate in diagnosing pulmonary TB and its greatest benefit is clearly demonstrated in smear-negative TB cases. However, the test is not free from some fallacies, even if they are a few, which draws our attention to the importance of the conventional culture for TB and the clinical correlation.
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Gender differences in pulmonary tuberculosis in Abbassia Chest Hospital p. 408
Tarek M Safwat, Eman B Abdel Fattah, Ahmed G Soliman
DOI:10.4103/ejb.ejb_97_18  
Background There is growing evidence that tuberculosis (TB) case notifications in men have in many circumstances surpassed those in women. The increase in reported cases among men was often interpreted as the result of barriers to TB diagnosis faced by women in seeking care. Aim To assess Gender differences in patients with pulmonary TB in Abbassia Chest Hospital. Patients and methods This study was carried out between 1 January 2017 and 30 April 2017. Patients were divided into two groups based on Gender difference: males and females. All patients were subjected to history taking, clinical examination, radiological and laboratory investigations, and sputum examination (direct smear and Gene Xpert and sputum culture for relapse TB, treatment failure, default, and suspected smear-negative patients). Pleural aspiration was done for cytological, biochemical, and adenosine deaminase level. Therapy was initiated, and patients were followed up for 6 months. Results The study has been carried out on 126 cases of TB, comprising 98 males and 28 females. The highest prevalence of TB infection among men with respect to different occupations was seen to be manual workers (62%), and among women to be housewives (71.4%). The new cases were 73.5% for males and 89.3% for females. The default was 14.3% for males and 3.6% for females. The frequency of relapse was 10.2% in males and 7.1% in females, whereas cases of treatment failure were found only in males. Male patients were much more compatible with anti-TB treatment. Drug complications were more common in women. In terms of treatment outcome, the rate of cure was higher in males and defaulters in females were more common. Conclusion In our study, the male-to-female ratio of identified patients with TB is higher than the previously reported global figures. Female patients were more likely to be younger, housewives, had longer symptoms duration before diagnosis, were less compatible with anti-TB therapy, and had more drug complications.
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Impulse oscillometry, an aid or a substitute? p. 416
Reham M Elkolaly, Salwa A Ganna, Doaa W Nada, Mohammed H Elnaggar
DOI:10.4103/ejb.ejb_98_18  
Introduction In the field of pulmonary medicine, respiratory mechanics and physiology are obviously affected by most pathological lesions and diseases, either primary disease or part of systemic ones. In the era of rheumatoid arthritis (RA), airway abnormality and interstitial lung pneumonia and/or fibrosis are the most common findings that face physicians during the disease course and affect morbidity, survival, and quality of life of patients with RA. Impulse oscillometry (IOS) is a noninvasive technique that needs minimal patient cooperation, which makes it suitable for any age including even children and can be performed by most patients. Aim of the work To describe the respiratory measures done by IOS in patients with RA and to correlate them with those measured by spirometry. Patients and methods A total of 60 patients with RA were recruited in this cross-sectional observational study. They were investigated via pulmonary function assessments, including spirometry and IOS, to measure forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and FEV1/FVC, and maximal expiratory flow at 25% (MEF 25%) in addition to R5% of predicted, R20% of predicted, R5–20, X5, and area under the curve. Results IOS measures indicated increased airway resistance (R5%, R20%, and R5–20) with decreased lung reactance (X5). Moreover, a positive correlation between disease duration and X5, between X5 and area under the curve and each of FEV1%, FVC%, and MEF 25%, whereas a negative correlation between R5–20 and each of FEV1%, FVC%, and MEF 25%. Conclusion IOS is an easy and rapid maneuver that requires minimal patient cooperation. It can identify lung affection in those who have mild or even normal spirometric changes. It is just a good screening test in patients with RA to detect early pathophysiologic lung changes. However, it needs further investigations to clarify the mechanism of these changes.
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Lung rockets and pulmonary functions p. 424
Sherif R.A El-Fatah, Radwa A El-Hefny, Randa I Ahmed, Doaa M.A El-Tawab
DOI:10.4103/ejb.ejb_55_18  
Introduction The ultrasound (US) of the chest is useful in the diagnosis of different parenchymal, pleural, and chest wall diseases. The US is preferred because no radiation is used (safe during pregnancy), is not expensive, is easy portability, provides real-time imaging, and has the ability to make a dynamic imaging. Aim This study aimed for the correlation between B-lines and spirometry, arterial blood gases, 6-minute walk test (6MWT), and pulmonary artery systolic pressure (PASP) in patients with diffuse parenchymal lung disease (DPLD). Design A prospective study was conducted. Setting The study was conducted at Fayoum University Hospital in Egypt between January 2017 and June 2017. Patients and methods This study was done on 60 patients with DPLD. They were subjected to a full medical history, a detailed clinical examination, high-resolution computed tomography, echocardiography, arterial blood gases analysis, spirometry, 6MWT, and chest US. Results The studied group showed female predominance, with 54 (90%) patients. They had a wide range of age from 20 to 75 years, and their mean age was 47.5±13.6 years. Most of them were involved in breeding birds, exposed to biomass, and nonsmokers. The studied patients had bilateral B-lines. The number of B-lines was positively correlated with PaO2, 6MWT, forced vital capacity, and PASP and negatively correlated with high-resolution computed tomography affection, whereas the distance between B-lines was inversely correlated with each of PaO2, numbers of B-line, 6MWT, forced vital capacity, and PASP. Most of patients had irregular and thickened pleura (71.6%), and abolished lung sliding was seen in 51.6%. Conclusion Chest US may be used in the evaluation of DPLD. Multiple B-lines with thickened and irregular pleural line are suggestive of DPLD.
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CASE REPORTS Top

Vocal cord disorders: uncommon causes of dyspnea p. 435
Animesh Ray, Sagnik Biswas
DOI:10.4103/ejb.ejb_70_18  
Dyspnea is a subjective sensation of difficult or uncomfortable breathing experienced by the patient. The etiology includes myriad causes starting from cardiopulmonary to psychogenic. The evaluation of dyspnea needs to be thorough so as to take into account all possible causes. Vocal cord disorders are a group of conditions uncommonly leading to dyspnea. These patients are usually wrongly labelled as difficult-to-treat asthma and consequently experience significant morbidity. Two cases of vocal cord disorders were presented with dyspnea and initially attributed to pulmonary causes and will be discussed in the present study.
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Scabbard trachea p. 441
Animesh Ray, Devada Sindhu
DOI:10.4103/ejb.ejb_92_18  
Scabbard trachea is a rare clinical observation, though commonly present in patients with chronic obstructive pulmonary disease. There is coronal narrowing of the intrathoracic part of the trachea resembling a saber sheath. We herein describe a case of scabbard trachea as a sequel of severe chronic obstructive pulmonary disease with the classical computed tomography and bronchoscopy findings.
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