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   Table of Contents - Current issue
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April-June 2019
Volume 13 | Issue 2
Page Nos. 139-288

Online since Friday, May 17, 2019

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ORIGINAL ARTICLES - AIRWAY DISEASES  

Leptin as a local inflammatory marker in chronic obstructive pulmonary disease acute exacerbation p. 139
Hossam H Masoud, Ahmed M Abd El-Hafeez, Mohamed S Ismail, Naef G Baharetha
DOI:10.4103/ejb.ejb_75_18  
Background Chronic obstructive pulmonary disease (COPD) is a disease of chronic inflammation affecting the lungs. Leptin is a pleiotropic cytokine thought to play a role in host inflammatory response. Aim This study aimed to investigate the role of leptin in sputum and serum as an inflammatory marker in acute exacerbation of COPD (AECOPD). Patients and methods Twenty patients with stable COPD, 20 patients with AECOPD, and 12 controls were included in this study. All participants were males. BMI, routine laboratory investigations, sputum and serum leptin levels, serum tumor necrosis factor (TNF-α), and C-reactive protein (CRP) levels were measured twice in patients with AECOPD (initially and after 7 days of management) and only once in stable patients and controls. Results In patients with patients with AECOPD, there were significant differences between sputum leptin and serum TNF-α, CRP, and leptin levels before and after treatment. Sputum leptin and serum CRP levels were significantly higher in the AECOPD group than other groups. Additionally, serum TNF-α levels were significantly higher in patients with AECOPD than the controls. Insignificant correlation was found between AECOPD and stable groups regarding serum leptin and TNF-α levels. Conclusion The present study highlights the role of leptin hormone as a local inflammatory marker in COPD acute exacerbation either in the sputum or the serum, together with serum TNF-α and CRP. These markers could be useful indicators of COPD acute exacerbation and its response to treatment.
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Metabolic syndrome; frequency and its relationship with variable parameters in chronic obstructive pulmonary disease p. 148
Azza Farag Said El-toney, Bahaa Ibrahim Mohamed, Emad Allam Abd-Elnaeem, Alaa Shaban Ismail
DOI:10.4103/ejb.ejb_51_18  
Background Chronic obstructive pulmonary disease (COPD) has many extrapulmonary comorbidities, and metabolic syndrome (MetS) is one of them. Scant data are available on MetS in Egyptian patients with COPD. Objective The purpose of the current research was to determine the frequency and clinical characteristics of MetS among Egyptian patients with stable COPD. Patients and methods A prospective study including 70 (64 males and six females) patients with stable COPD was conducted. Clinical assessment, pulmonary function, and other laboratory studies were performed. Results MetS was present in 31 patients with COPD (44.3%). BMI and high-sensitivity C-reactive protein were significantly higher in patients with COPD with MetS than those without MetS (P=0.02 and 0.01, respectively). Age of the patients, duration of COPD, grade of dyspnea, and pulmonary function tests had no significant difference between those with MetS versus those without it. There was a significant negative correlation between plasma triglyceride level, as the only one of the variables of MetS, and some of parameters of pulmonary function test. Conclusion MetS is relatively frequent among patients with COPD. Plasma triglyceride level is the only parameter of MetS to have a significant correlation with pulmonary function tests. Apart from BMI and high-sensitivity C-reactive protein, no other parameter among patients with COPD has a significant relationship with MetS.
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ORIGINAL ARTICLES: BRONCHOSOCOPY & INTERVENTIONAL PULMONOLOGY Top

The role of medical thoracoscopic lung biopsy in diagnosis of diffuse parenchymal lung diseases p. 155
Magdy M Omar, Ahmad S Alhalafawy, Nashwa M Emara, Mohammad A.E El-Mahdy, Etemad Abdelsalam
DOI:10.4103/ejb.ejb_41_18  
Background Interstitial lung disease in the immunocompetent patient is often a difficult challenge for the clinician, especially when no diagnostic clues are present. A clear diagnosis confirmed by biopsy allows clinicians and patients to discuss fully the implications of the disease. Aim The aim was to evaluate the role of medical thoracoscopic lung biopsy in diagnosis of patients with diffuse parenchymal lung diseases. Patients and methods The study included 15 patients with diffuse parenchymal lung diseases of unknown etiology. They had undergone full history taking, complete clinical examination, ventilatory function tests (spirometry), arterial blood gases analysis, high-resolution computed tomography chest, coagulation profile, platelet count, collagen profile, and thoracoscopic lung biopsy by medical thoracoscopy for histopathologic examination. Follow-up of the patients in the inpatient unit was done by chest radiography and clinical evaluation. Results The pathological diagnosis of cases was six (40%) patients with extrinsic allergic alveolitis, five (33.3%) patients with malignancy, three patients with idiopathic interstitial pneumonias, one (6.7%) patient with tuberculosis, and one (6.7%) patient with sarcoidosis. Regarding complications, one (6.7%) patient had pneumothorax after intercostal tube (ICT) removal, and three (20%) patients had subcutaneous emphysema. The duration of the ICT drainage was 3.1±2.6 days. There was no wound infection, no bleeding, no persistent air leak after more than 24 h (Hs) from ICT insertion, no respiratory failure requiring ICU admission, and no mortality in the study sample. Conclusion Thoracoscopic lung biopsy by medical thoracoscopy is useful in diagnosis of cases with diffuse parenchymal lung diseases of unknown etiology when lung biopsy is needed for accurate diagnosis. The procedure is safe. The procedure carries some complications that are not life threatening and can be minimized by good selection of patients.
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Thoracoscopic pleural cryobiopsy versus conventional forceps biopsy in diagnosis of exudative pleural effusion of unknown etiology p. 162
Randa S.E Muhammad, Sabah A.M Hussein, Mohammad F Mohammad, Marwa M Ahmed, Gehad A Ali
DOI:10.4103/ejb.ejb_72_18  
Background Rigid forceps is commonly used for pleural biopsies during medical thoracoscopy in undiagnosed pleural effusion, and recently, the use of cryoprobe for pleural biopsies was encouraged, as the procedure is effective and safe. Objective This study compared between rigid forceps and cryoprobe pleural biopsies regarding biopsy characteristics, diagnostic yield, and tissue viability in patients with undiagnosed exudative pleural effusion who underwent medical thoracoscopy. Patients and methods A total of 30 patients with undiagnosed exudative pleural effusion were selected for medical thoracoscopy, and pleural biopsies were taken by rigid forceps and cryoprobe in the same setting. All biopsies were processed for histopathology examination. Results Of the 30 patients, 18 (60%) were males and 12 (40%) were females, with mean age of 51.03 years. The most frequent diagnosis was mesothelioma (43.3%) followed by chronic nonspecific inflammation (23.3%), metastatic carcinoma (16.6%) and tuberculosis (16.6%). Biopsies of rigid forceps (mean: 0.8193 cm2) were larger than cryoprobe (mean: 0.3377 cm2) but with less depth. Tissue viability of cryoprobe biopsies was better than rigid forceps biopsies, and the diagnostic yield of both techniques was the same. Conclusion Cryobiopsies obtained during medical thoracoscopy is technically feasible and safe with high diagnostic value. Biopsies of cryoprobe were smaller than that of rigid forceps but were deeper and with better preserved cellular architecture. These results will encourage the use of cryotechnique for diagnosis of undiagnosed exudative pleural effusion.
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ORIGINAL ARTICLES: CRITICAL CARES Top

Assessment of gradient between partial pressure of arterial carbon dioxide and end-tidal carbon dioxide in acute respiratory distress syndrome p. 170
Fatmaalzahraa S Abdalrazik, Mohamed O Elghonemi
DOI:10.4103/ejb.ejb_90_17  
Context End-tidal carbon dioxide (EtCO2) is used as a noninvasive bedside test to assess the adequacy of ventilation and physiologic dead space in mechanically ventilated patients. The gradient difference between EtCO2 and partial pressure of arterial carbon dioxide (PaCO2) is directly related to an increase in the physiologic dead space. Aim The aim of this study was to evaluate the role of measuring the gradient between EtCO2 and PaCO2 in adults with acute respiratory distress (ARDS). Settings and design This was a prospective consecutive enrollment study. Patients and methods Overall, 51 cases were recruited after the diagnosis of ARDS was made according to the Berlin definition. Patients were mechanically ventilated as per the lung-protective protocol. Daily arterial blood gases were collected and for every sample, the EtCO2 value was collected electronically by capnography using an endotracheal tube for the first 5 days. Results Cases were classified into survivors and nonsurvivors: 26 cases were because of extrapulmonary causes and 25 cases were because of pulmonary causes. The mean value of the APACHE II score for all cases on admission was 21.6. The mean length of ICU stay was 12.7 days. For all study cases, PaO2/FiO2 was the lowest at day 1 and the highest at day 5. We found a significant negative correlation between PaO2/FiO2 and the gradient at days 2, 4, and day 5, and a significant positive correlation between the gradient on admission and the APACHE II score (r=0.4, P≤0.05). Nonsurvivors had a significantly higher gradient and lower EtCO2 and PaO2/FiO2 levels at all time intervals, whereas PaCO2 alone was found to be nonsignificant. Conclusion In ARDS, EtCO2 and gradient are reliable indicators of severity.
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Postintensive care syndrome in mechanically ventilated patients secondary to respiratory disorders p. 176
Mohammed A Agha, Mahmoud M El-Habashy, Mohammed S Abdelshafy
DOI:10.4103/ejb.ejb_58_18  
Background Patients admitted to ICU, especially those who are mechanically ventilated, are under the effects of many clinical, therapeutic, and emotional stress factors that usually lead to different physical, psychological, and cognitive disabilities. These acquired disabilities are called postintensive care syndrome (PICS). Objective the aim was to detect any component of PICS in mechanically ventilated patients at respiratory ICU (RICU) after being discharged from ICU. Patients and methods All recruited patients were assessed at three time points: first during admission to RICU, where all clinical and laboratory data were recorded; second following discharge from RICU, and third following 1 month of discharge from hospital. During the second and third points, cognitive, psychological, and physical components of PICS were assessed. Results A total of 20 (50%) patients developed one or more component of PICS. There were highly significant differences between patients with and without PICS regarding age, duration of mechanical ventilation, duration of ICU admission, level PaO2, acute physiology and chronic health evaluation (APACHE) IV score, the presence of co-morbidities, and the process of weaning. There were highly significant positive correlations between age of patients, duration of mechanical ventilation and ICU stay, and the score of APACHE IV and the development of PICS, whereas there was a highly significant negative correlation regarding the level of PaO2. Conclusion Patients with respiratory disorders admitted to the RICU should be evaluated and followed up for the detection of any components of PICS especially those who are old adult, have prolonged intubation or ICU stay, have co-morbidities, high APACHE IV score, and persistent hypoxemia.
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ORIGINAL ARTICLES - CRITICAL CARE Top

Assessment of diaphragmatic mobility by chest ultrasound in patients with chronic obstructive pulmonary disease on different modes of mechanical ventilation Highly accessed article p. 184
Adel M Saeed, Ashraf A El Maraghy, Riham H Raafat, Ahmed M Abd Elsamad
DOI:10.4103/ejb.ejb_99_18  
Background Chronic obstructive pulmonary disease (COPD) is a disease characterized by airway obstruction and air trapping that is not fully reversible. The diaphragm is the principal respiratory muscle, and its dysfunction can prolong the duration of mechanical ventilation. Ultrasonography is a fast, easy, and accurate method of bedside evaluation for diaphragmatic function. In the ICU population, it can quantify normal and abnormal movements in a variety of clinical conditions. Patients and methods A prospective observational study was carried on 32 patients with COPD admitted to the respiratory ICU. Diaphragmatic excursion had been assessed by chest ultrasonography in every mode of mechanical ventilation and was correlated with weaning off mechanical ventilation and other physiological parameters. Results Of 32 patients with COPD included in the study, 24 patients were successfully weaned versus eight patients failed to be weaned off mechanical ventilation. Diaphragmatic excursions in every mode of mechanical ventilation (noninvasive, volume control, bilevel positive airway pressure, and pressure support) were higher in weaned patients with best cutoff values of 1.4, 1.3, 1.5, and 1.6 cm, respectively. Moreover, the diaphragmatic excursions were directly correlated with tidal volumes and inversely correlated with days of mechanical ventilation and rapid shallow breathing index. Conclusion Diaphragmatic displacement assessed by ultrasound is a good predictor for weaning off mechanical ventilation in patients with COPD, as it is sensitive, specific, and accurate. Diaphragmatic excursions are directly related to tidal volumes and inversely related with rapid shallow breathing index and days of mechanical ventilation.
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ORIGINAL ARTICLES: CRITICAL CARES Top

Diaphragm ultrasound as a predictor of successful extubation from mechanical ventilation p. 191
Taher Abd El Hamid El Naggar, Ibrahim A Dwedar, Eman F.A Abd-Allah
DOI:10.4103/ejb.ejb_59_18  
Background Ultrasonography can be used for assessment of diaphragmatic mobility and thickness. Diaphragm is the main muscle of respiration. Rationale To predict successful extubation from mechanical ventilation. Patients and methods Forty patients were involved in the present study. They were admitted in the ICU at Abbassia Chest Hospital. They received the conventional measurements for weaning and transdiaphragmatic ultrasonography after extubation. We assessed the diaphragmatic mobility and diaphragmatic thickening fraction. All ultrasonography findings were gathered and compared with some of the usual weaning tools such as arterial blood gas and respiratory mechanics. The findings were statistically analyzed. Results Thirty-one patients revealed successful liberation from mechanical ventilation. Diaphragmatic mobility and thickening fraction showed high sensitivity and specificity compared with other weaning tools. The cutoff value was 10 mm for mobility and 30% for diaphragmatic thickening fraction. Conclusion Diaphragmatic ultrasonography can be used as a new tool for prediction of weaning process.
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ORIGINAL ARTICLES: DIFFUSE PARENCHYMAL LUNG DISEASES Top

Serum level of carbohydrate antigen 15-3 in patients with interstitial lung diseases and its correlation with pulmonary function and high-resolution computed tomography p. 196
Randa Salah El-Din Mohamed, Mahmoud Mohammed El-Batanouny, Neveen Mahmoud Amin, Rasha Abdel Razek Mahmoud, Doaa A.A Abd-Elhalim
DOI:10.4103/ejb.ejb_47_18  
Background Carbohydrate antigen 15-3 (CA15-3) is a central protein core of mucin-1, a high-molecular-weight glycoprotein, found in alveolar and extrapulmonary epithelial cells that increases in interstitial lung disease. It uses antibodies against different epitopes. It is also considered a tumor marker for breast cancer. Aim The aim was to evaluate the value of CA15-3 as a biomarker in patients with interstitial lung diseases and to evaluate the correlation between CA15-3 level and radiological findings in high-resolution computed tomography (HRCT) and pulmonary function in patients with interstitial lung diseases (ILDs). Materials and methods The study was performed on 60 adult patients with ILD and 20 healthy controls. We classified the patients into three groups according to HRCT findings: group I ground glass (18 patients), group II reticulation (27 patients), and group III honeycombing (15 patients). All patients were subjected to HRCT, spirometry, collagen markers, and serum CA15-3 level evaluation. Results CA15-3 level in patients with ILD was significantly higher than control (P<0.001). CA15-3 level in reticulation and honeycombing groups was significantly higher than ground glass group, and CA15-3 level in reticulation group was significantly higher than honeycombing group (P=0.003). This may be explained by that reticulation is active fibrosis, whereas honeycombing is established fibrosis. A significant negative correlation has been noticed between CA15-3 level and forced vital capacity in the three different groups (P<0.05, r=−0.304). Conclusion The serum level of CA15-3 is strongly elevated in patients with ILD. CA15-3 is a noninvasive, nonexpensive, rapid biomarker in ILD, being proportional to the extent of lung injury.
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Fayoum experience in the ultrasonographic evaluation of diffuse parenchymal lung disease p. 204
Sherif Refaat Abd El Fatah, Radwa Ahmed Elhefny, Randa Ibrahim Ahmed, Doaa Mohamed Abd El Tawab
DOI:10.4103/ejb.ejb_54_18  
Objective Chest ultrasound has many uses, both diagnostic and interventional. It may be used for the diagnosis of multiple pleural diseases (pleural effusion, pleural masses, and pneumothorax). It is also used in the diagnosis of diseases caused by lung parenchymal lesions, such as neoplasms, pulmonary embolism, pneumonia, and lung abscesses. Aim This study aimed to evaluate the sonographic features of diffuse parenchymal lung disease (DPLD). Design This was a prospective study. Setting The study was carried out at Fayoum University Hospital in Egypt during the period spanning from January 2017 to June 2017. Patients and methods This study included 120 participants. Sixty of them were diagnosed as having DPLD. For the diagnosis of these cases, we need a full medical history, a detailed clinical examination, spirometry, 6 min walk test, arterial blood gases’ analysis, high-resolution computed tomography, and chest ultrasound. The other 60 were studied as controls. Statistical analysis The data were collected and coded to facilitate data manipulation, and they were double entered into Microsoft Access; the data analysis was performed by using SPSS software, version 18 in Windows 7. The simple descriptive analysis was carried out in the form of numbers and percentages for qualitative data and arithmetic means as central tendency measurement, SDs as measure of dispersion for the quantitative parametric data and the inferential statistic test. Results There was a female predominance with a wide range of age. Most of the cases were nonsmokers, breeding birds, and exposed to biomass. All cases had diffuse bilateral B-lines. There was a negative relation between the Warrick score on the one hand and the B-line number, PaO2, 6 min walk test, and forced vital capacity on the other hand. In contrast, a positive relation was demonstrated between the Warrick score and B-line distance and pleural thickness. Most of the studied patients (71.6%) had irregular and thickened pleura and (51.6%) had an abolished lung sliding. Conclusion Chest ultrasound has a significant role in the diagnosis of DPLD and also in estimating the severity of the disease according to the number and the distance between B-lines. Multiple B-lines in the combination of thickened and irregular pleural line are highly suggestive of DPLD.
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Plasma surfactant protein-D as a potential biomarker in idiopathic pulmonary fibrosis p. 214
Mohamed A El Nady, Safy Z Kaddah, Yasmine H El Hinnawy, Radwa M. A Halim, Reham H Kandeel
DOI:10.4103/ejb.ejb_74_18  
Objectives Idiopathic pulmonary fibrosis (IPF) is a disease of an increasing burden. Its diagnosis is based on definite high-resolution computed tomography pattern and is associated with the histopathological and/or radiological pattern of usual interstitial pneumonia with exclusion of other causes of interstitial pneumonia. The surfactant protein-D (SP-D) level in the serum is measured in several lung diseases, including IPF. Aim of study The aim of the current study is to assess the serum level of SP-D as a potential biomarker to distinguish between IPF and other idiopathic interstitial pneumonia patients. Patients and methods This study was conducted in the Chest Department, Kasr Al Ainy Hospitals, Cairo University. The study population included 20 healthy controls, 20 IPF patients, and 18 other idiopathic interstitial pneumonia patients. All were subjected to full history taking, clinical examination, high-resolution computed tomography chest, spirometry, arterial blood gases, blood samples for measuring SP-D by enzyme-linked immunosorbent assay. Results There was no statistical significance between the serum level of SP-D in IPF and non-IPF patients, however, there was a significant increase in the serum level of SP-D in IPF patients diagnosed at a late stage compared with those diagnosed at an early stage and those on anti-fibrotic therapy. Also, there was a statistical significance between the degree of clubbing and gastroesophageal reflux disease and the serum level of SP-D with a P value of 0.005 and 0.029, respectively. Serum SP-D level had a negative correlation with more severe form of the disease regarding the duration of illness, forced vital capacity percent, and it had a significant negative correlation with oxygen saturation and 6 min walk distance with a P value of 0.023 and 0.005, respectively. Conclusion The level of serum SP-D level in IPF patients correlate well with the severity of the disease and could be a possible marker to use for the follow up of patients on anti-fibrotic drugs.
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Impact of pulmonary rehabilitation on patients with interstitial lung diseases: an Egyptian experience p. 219
Howida M El-Komy, Mohammed Awad, Waleed Mansour, Enaam I Elsayed
DOI:10.4103/ejb.ejb_64_18  
Background Dyspnea, cough, fatigue, functional limitation, and low quality of life (QOL) are manifestations of almost all interstitial lung diseases (ILDs), with little effective and may be well-tolerated pharmacotherapy in most of its subtypes. The application of pulmonary rehabilitation (PR) may have some benefits in patients with ILDs. Aim The aim of this study was to evaluate the effect of PR program on ILD patients’ QOL, exercise capacity, dyspnea, and spirometry. Settings and design This was a single-center experimental randomized controlled study. Patients and material This study initially enrolled 62 patients previously diagnosed as having ILD at the Chest Department according to American Thoracic Society (ATS)/European Respiratory Society (ERS) diagnostic criteria; however, 12 patients were excluded, and only 50 patients were included and completed the study, and they were classified randomly into the control group (n=25, received conventional treatment only) and the PR group (n=25, received conventional treatment and PR). Pre-PR and post-PR program assessment of QOL by the 36-item short-form health survey (SF36) questionnaire, exercise capacity by the 6-min walk test, dyspnea by the modified Medical Research Council and spirometry were carried out. Statistical analysis used All data were collected, tabulated and statistically analyzed using SPSS 16.0 for Windows. Results This study showed a statistically significant difference for the PR group over the control group at the end of the PR program, wherein all components of the SF36Q score had a P value less than 0.05, dyspnea score by modified Medical Research Council (P=0.02) and exercise tolerance by 6 min walking distance test (P=0.005). Moreover, the maximum voluntary ventilation (MVV%) showed a statistically significant improvement (P=0.003) in contrast to the other measured spirometric parameters measured in this study (forced vital capacity, forced expiratory volume in 1 s, forced expiratory volume in 1 s/forced vital capacity %, forced expiratory flow25–75) wherein P value was more than 0.05. A negative correlation was found between the baseline physical functioning item of SF36Q and the change (Δ) in 6 min walk distance test. Conclusion PR could be considered as an adjuvant method in the treatment of patients with stable ILDs and could provide improvement in their dyspnea perception, exercise tolerance, and health-related QOL.
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Predictors of erectile dysfunction among male patients with idiopathic interstitial pneumonias p. 226
Doaa M Magdy, Ahmed M Azouz, Randa A El Zohne
DOI:10.4103/ejb.ejb_66_18  
Background Sexual dysfunction is a neglected area among patients with idiopathic interstitial pneumonias (IIPs). Hence, the aim of this study is to identify the prevalence of erectile dysfunction (ED) and its predictors in male patients with IIPs. Patients and methods A total 65 male patients (45 IIPs and 20 controls) were assessed; clinical data, testosterone levels, pulmonary function tests, arterial blood gases, and self-reported questionnaires on erectile function. Results The prevalence of ED was 66.7 and 11.1% of them presented with severe ED. The mean age of the patients was 33.4±5.9 years. Of the patients, 60% were smokers and 17.8% were nonsmokers. Regarding comorbid manifestations, 26.7% was hypertensive, 51.1% had diabetes mellitus, 42.2% with dyslipidemia, and 17.8% had ischemic heart disease. The mean duration since the diagnosis of IIPs was 7.46±2.77 years, whereas the mean time since evolution of ED was 2.17±1.3 years. A significant decrease in mean arterial oxygen tension (PaO2) and oxygen saturation (SaO2) were observed in the IIPs group. Also, the mean diffusion lung capacity for carbon monoxide (DLCO%) and testosterone level were decreased. A significant decrease in testosterone level among patients with severe diffusion defect was observed (P=0.000). The most predictors for ED were PaO2 (≤60 mmHg), SaO2 (≤88%), and DLCO≤60%. Conclusion ED is a common problem in patients with IIPs. Thus, physicians should keep in mind that IIPs patients need a comprehensive sexual evaluation. This is the first study to report that low PaO2, SaO2, and DLCO≤60% were the predictor risk factors.
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ORIGINAL ARTICLE: MISCELLANEOUS Top

Assessment of diaphragmatic mobility by chest ultrasound in relation to BMI and spirometric parameters p. 232
Saeed M Adel, Ezzelregal G Hieba, Sayed H Hossam
DOI:10.4103/ejb.ejb_73_18  
Context Ultrasound of the diaphragm is an evolving diagnostic modality with several techniques and measurements that can be used for structural and functional assessment of the diaphragm. Weight may have effects on pulmonary function tests including its impairment. Assessment of the diaphragm is one of these important measures of function by measuring the diaphragmatic thickness, excursion, and diaphragmatic thickness fraction (DTF). Aim Assessing the relation between these sonographic diaphragmatic indices with spirometry and BMI. Settings and design This was a prospective clinical study in which 107 normal healthy volunteers with different age, height, and weight were enrolled; most of them were coming for routine preoperative assessment at the Ain Shams University Chest Department Pulmonary Function Unit. Patients and methods It included 107 healthy persons who came for routine preoperative lung function assessment or normal volunteers. Full medical and smoking history, BMI, chest radiography spirometry, and diaphragmatic assessment by ultrasound for excursion, thickness, and DTF were done. All persons were divided into obese individuals of BMI more than or equal to 25 and nonobese individuals of BMI less than 25. Statistical analysis Statistical package for the social sciences program (SPSS) software version 18.0. Results In obese individuals, forced expiratory volume in the first second (FEV1%) and right diaphragmatic excursion show a significant decrease when BMI increases. There was a statistically significant increase in right and left diaphragmatic excursion and DTF in men rather than women. There was a highly significant increase in both right and left diaphragmatic thickness and excursion when forced vital capacity increases. There was a highly significant increase in right diaphragmatic excursion and both right and left diaphragmatic thickness when FEV1 increases. A significant increase in left excursion and DTF was also noticed with increased FEV1. However, there was a significant decrease in DTF with increased percent of forced vital capacity. Conclusion Spirometric parameters and right diaphragmatic excursion show a significant decrease when BMI increases. Different relations were found between spirometric parameters and ultrasonographic measurements regardless of the BMI.
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ORIGINAL ARTICLE - PLEURAL DISEASES Top

Is computed tomography scan able to replace laboratory tests to differentiate transudate effusions from exudate effusions? that is a question p. 244
Yousef Ahmed, Sahar Farghly, Mohamed I Seddic, Shimaa Farghaly
DOI:10.4103/ejb.ejb_37_18  
Background Pleural effusion is considered an interesting clinical problem that is commonly faced by physicians and is caused by several diseases. The ability of computed tomography (CT) to differentiate transudate effusion from exudate effusion is still under research. Objective The aim of this study was to assess the accuracy of the CT in diagnosing the nature of the pleural effusion. Patients and methods In this prospective cross-sectional analytic study, laboratory biochemistry markers were used to classify pleural effusion into exudate or transudate based on Light’s criteria. Chest CT without contrast had been done for all patients, and CTs were diagnosed by the radiologist. Measurement of the pleural fluid density was done and shown using the CT attenuation values [Hounsfield unit (HU)]. Results Of 79 patients with pleural effusion, 60 patients had exudate effusion and 19 patients had transudate. The mean attenuation values were significantly higher in exudate effusion (20.11±7.11 HU) versus transudate effusion (13.8±4.11 HU), with P value of 0.03. Receiver operating characteristic curve analysis showed that the cutoff for exudate effusion was optimal at greater than or equal to 15.33 versus less than 15.33 HU for transudate (area under the curve=0.57; 95% confidence interval: 0.45–0.68). This point had 85.71% sensitivity and 46.55% specificity. Conclusion We reasoned the CT attenuation values of the pleural fluid may replace the laboratory tests in characterizing the pleural effusion, either exudate or transudate. However, there was an overlapping HU values in most effusions. So correlation of the CT results with the clinical findings is essential, and further CT studies are highly recommended to confirm and validate these findings.
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ORIGINAL ARTICLES - PULMONARY INFECTIONS Top

The impact of adjuvant atorvastatin therapy on community-acquired pneumonia outcome: a prospective study of clinical and inflammatory responses in relation to mortality reduction p. 249
Yasser M Mohamed, Ashraf M Madkour, Rehab M Mohammed, Mohamed G El-Shiekh
DOI:10.4103/ejb.ejb_50_17  
Introduction In treatment of pneumonia, new drugs besides antibiotics are investigated; especially statins with their anti-inflammatory, immunomodulatory, and antioxidant effects. Objective The aim was to determine whether or not adjuvant atorvastatin could improve 30-day mortality, and clinical and inflammatory outcomes of community-acquired pneumonia (CAP). Patients and methods This is a prospective study, in which 47 CAP patients were randomized into: statin naive, n=23 (received antibiotics according to guidelines) and statin users, n=24 (received antibiotics according to guidelines+atorvastatin 40 mg daily for 30 days). Total leukocytic count and C-reactive protein (CRP) were measured, pneumonia severity index was estimated on the first day and on the seventh day, and length of hospital stay and mortality were also recorded. Results Statin users showed statistically significant reduction of CRP (P=0.049) and significantly shorter hospital stay (P<0.001). No statistically significant difference on comparing both groups as regard the reduction magnitude of total leukocytic count (P=0.406), pneumonia severity index (P=0.325), and mortality (P=0.489). Conclusion Incorporating atorvastatin therapy with antibiotics compared to antibiotics alone in the treatment of CAP showed significantly lower CRP levels, shorter hospital stay, but no impact on mortality reduction.
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Incidence of ventilator-associated pneumonia: Egyptian study p. 258
Reham M Elkolaly, Hoda M Bahr, Basem I El-Shafey, Ahmed S Basuoni, Eman H Elber
DOI:10.4103/ejb.ejb_43_18  
Background Despite different ICU admission causes, ventilator-associated pneumonia (VAP) is still a common cause of mortality and morbidity in intubated patients and impedes obvious progression in diagnostic modalities and management of these infections. Aim of study The aim of this study was to estimate VAP incidence in Tanta University Hospitals ICUs. Settings and design This was a crossover observational study. Patients and methods This was a one-year study (April 2015 to March 2016), including patients on invasive ventilation who developed VAP, with evaluation of admission and ventilation causes, isolation of causative organisms, and study of used antibiotics and ventilation modes. Statistical analysis Data were statistically analyzed using the SPSS software for Windows (IBM SPSS Statistics 21.0). Results It is a statistics based study aimed to trace infection incidence in national hospital ICUs. Among 222 admitted patients, only 38.4% fulfilled the criteria of VAP. Admission was because of cardiovascular impairment, cardiac arrest, respiratory failure, or head trauma. The ventilation mode at VAP time was assisted control (75%) and synchronized intermittent mandatory ventilation (25%). The minimum intubation period was 7 days, whereas the maximum period was 37 days. Isolated organisms were Pseudomonas (37.5%), Klebsiella (25%), Staphylococcus (20.8%), and methicillin-resistant Staphylococcus aureus (4.2%). The antibiotics used were amikacin, imipenem, vancomycin, levofloxacin, ceftazidime, and teicoplanin (29, 25, 21, 12.5, 8.3, and 4.2%, respectively). The minimum period of antibiotic used was 5 days, whereas the maximum period was 35 days. The highest incidence of VAP occurred in February, whereas the lowest incidence occurred in July. Conclusion The incidence of VAP is still high and varies according to the intubation cause and period, and the underlying morbidity. More efforts must be made to prevent, diagnose, and manage infection early and properly to reduce patient suffering and to reduce the burden on the serving hospitals.
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Role of ‘patient sensitization on patient charter’ for tuberculosis care and support: The beneficiaries’ perspective p. 267
Janmejaya Samal, Subbanna Jonnalagada, Nishant Ekka, Laxmidhar Singh
DOI:10.4103/ejb.ejb_45_18  
Background Improvement of knowledge regarding the rights and responsibilities of patients with tuberculosis (TB) (patient charter) through sensitization meeting may have a positive effect on their life and yield better treatment outcomes. Participants and methods With the objective to understand beneficiaries’ (who availed TB care and support services) perspective, 30 patient interviews from eight districts of Jharkhand were conducted with a semistructured questionnaire. The sample was drawn from 120 cured patients with TB of 770 patients with TB sensitized on patient charter. Results Of 30 respondents, 23.3% (7, n=30) are female; 6.6% (2, n=30) belong to extrapulmonary cases; 10% (3, n=30) and 6.6% (2) are diagnosed through fine needle aspiration cytology and chest radiography modes, respectively; and all of them got detected at public health facilities. Most of the respondents are empowered completely or partially. Overall, 56.6% (17, n=30), 13.3% (4, n=30) and 30% (9, n=30) of the respondents are satisfied, unsatisfied, and neutral about patient charter role on treatment outcome. Only 13.3% (4, n=30) acted as TB ambassadors. Three thematic areas emerged out of this study: empowered patients with TB [100%, (30, n=30)], content patients with TB [56.6% (17, n=30)], and TB ambassadors [13.3% (4, n=30)]. Here empowered patients with TB refers to those who acquired the requisite knowledge about TB, content patients with TB refer to those who are satisfied with the information and services of patient charter meeting, and TB ambassadors are those who helped the neighborhood in getting rid of TB. Moreover, empowerment is considered when knowledge-related questions were responded properly, and satisfaction is considered when needed information and services were offered leading to better treatment outcome. Conclusion It is evident from the study that the patient charter has substantially empowered the attendees in getting positive treatment outcome; however, further improvement is needed with the help of other stakeholders involved in TB control. Moreover, the charter should be creating more TB ambassadors which would help in mobilizing the community to identify the hidden cases of TB for control through ‘word of mouth’.
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ORIGINAL ARTICLES: PULMONARY VASCULAR DISEASES Top

Can alveolar–arterial oxygen gradient predict severity of pulmonary embolism? p. 273
Elham Abdelhady Abdelghany, Ashraf M Othman, Rasha Abdelraof Abdelfatah, Mohammed-Elhoseany Magdy, Hosny S. Abd Elghany, Mahmoud M Higazi
DOI:10.4103/ejb.ejb_62_18  
Background The perceived risk for pulmonary embolism (PE) can be assessed by oxygenation and calculation of the alveolar–arterial (A-a) oxygen (O2) gradient. We attempt to evaluate the efficacy of A-a O2 gradient for the diagnosis of PE and if it can predict the degree of severity of PE. Patient and methods This study is a prospective study conducted on 70 patients presented by signs or symptoms of suspected acute PE. Arterial-blood gases including arterial partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (PaCO2), and arterial oxygen saturation (SaO2) and computed tomography pulmonary angiography were done on admission. Results Fifty patients proved to have PE by computed tomography pulmonary angiography. The patients were divided into (a) nonhigh-risk and (b) high-risk groups. There was a significant difference between the two groups regarding pulmonary artery obstructive index. Although A-a gradients were high in all studied patients with positive PE in comparison to negative PE patients, there was no significant difference between high-risk and nonhigh-risk groups regarding PaO2 (mmHg), arterial oxygen saturation, %, A-a O2, PaCO2. In addition, no significant relationship was detected between arterial-blood gas parameters regarding PaO2 and SaO2 with pulmonary artery obstructive index; also PaCO2 and A-a O2 gradients were nonsignificant. Conclusion The A-a O2 gradient values are clinically important in the diagnosis of patients with PE because it is easy to perform and is a bedside test. However, it may be incapable of detection of severity of PE.
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Study of connective tissue disease-associated pulmonary hypertension p. 280
Mona M Ahmed, Iman H Galal, Ayman A.H Farghaly, Ashraf A Gomaa, Mohamed Abd El Monem Mohamed
DOI:10.4103/ejb.ejb_33_18  
Background Screening for pulmonary arterial hypertension (PAH), a leading cause of death in systemic sclerosis, facilitates earlier treatment. The aim of this work was to study connective tissue disease (CTD)-associated PAH guided by ‘DETECT’ algorithm. Patients and methods This study was a prospective cross-sectional study conducted on 30 patients with CTDs, including 16 cases with systemic sclerosis, nine cases with systemic lupus erythromatosis, and five cases with rheumatoid arthritis. Results According to right heart catheterization finding, estimated total sensitivity and specificity of step 1 and step 2 in diagnosis of PAH among all cases were 80 and 64%, respectively. Conclusion The novel, evidence-based DETECT algorithm for PAH detection in CTDs is a sensitive, noninvasive tool and addresses resource usage.
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CASE REPORT Top

Size matters: an unusual case report p. 286
Abhenil Mittal, Animesh Ray, Sagnik Biswas, Chandan Das
DOI:10.4103/ejb.ejb_69_18  
Mounier-Kuhn syndrome is a rare clinical entity characterized by dilation of the tracheobronchial tree leading to recurrent lower respiratory tract infections. The clinical spectrum ranges from asymptomatic patients to those with severe respiratory failure. The disease is diagnosed by the use of computerized tomography scans, bronchoscopy, and pulmonary function tests of the affected patients. There is no specific medical or surgical therapy for the entity, and care is largely supportive, targeted towards prevention of infections in such patients. We describe the case of a 27-year-old male who presented to us with complaints of paroxysmal episodes of cough with expectoration on and off since childhood. Computerized tomography scans revealed dilation of the trachea (diameter 33.7 mm) with bronchiectatic changes noted in the right lower lung lobe. Virtual bronchoscopy revealed tracheal scalloping and diverticulae which further substantiated the diagnosis of Mounier-Kuhn syndrome. Pulmonary function test result was normal.
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