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   Table of Contents - Current issue
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April-June 2018
Volume 12 | Issue 2
Page Nos. 137-276

Online since Wednesday, May 23, 2018

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REVIEW ARTICLE  

Spontaneous pneumothorax: time to depart from the ‘chest tube underwater seal’? Highly accessed article p. 137
Maged Hassan, Hany Shaarawy
DOI:10.4103/ejb.ejb_58_17  
Initial management of spontaneous pneumothorax has traditionally been inserting a chest tube and attaching it to an underwater seal and hospitalizing the patient. New options have emerged that allow management to be on an outpatient basis without the need for hospitalization. These options are needle aspiration (similar to aspiration of effusion) or attaching the chest tube to a one-way valve. So, is chaining a patient with spontaneous pneumothorax to their hospital bed because of the heavy jar attached to the chest tube the most prudent way of management? This review attempts to answer this question.
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CRITICAL CARE Top

Noninvasive positive pressure ventilation in acute hypercapnic respiratory failure Highly accessed article p. 143
Khaled Hussein
DOI:10.4103/ejb.ejb_65_17  
NPPV is well established in the management of acute on chronic hypercapnic respiratory failure secondary to acute exacerbation of COPD (AECOPD), obesity hypoventilation syndrome, and restrictive thoracic disorders. Because of its design, success depends largely on patient cooperation and acceptance. The most commonly used interfaces in acute hypercapnic respiratory failure are oronasal masks. During noninvasive ventilation patients respiratory system is maintained throughout the whole respiratory cycle at a constant pressure higher than the atmospheric pressure, usually termed the positive end-expiratory pressure (PEEP). Pressure support ventilation (PSV), is the most famous mode of partial ventilatory support that during spontaneous inspiratory efforts imposes a set level of positive pressure in a patient with intact respiratory drive. Bilevel positive airway pressure (BiPAP) include PSV during inspiration and EPAP during expiration. The highest pressure reached during inspiration is called inspiratory positive airway pressure (IPAP) which equal PSV + EPAP.
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ORIGINAL ARTICLES - AIRWAY DISEASES Top

Effectiveness of pulmonary rehabilitation on pulmonary function parameters and dyspnea in patients with stable chronic obstructive pulmonary disease p. 149
Atef F Al Karn, Wafaa A Hassan, Abdel A Abo El Fadl, Manal A Mahmoud
DOI:10.4103/ejb.ejb_43_16  
Background Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable disease characterized by persistent airflow limitation that is usually progressive. The characteristic symptoms of COPD are chronic and progressive dyspnea, cough, and sputum production. Breathing exercises aim to reduce hyperinflation, improve respiratory muscle performance, and reduce dyspnea. Aim The aim of the study was to assess the effectiveness of breathing exercises among patients with stable COPD in improvement of pulmonary function parameters, 6-min walk distance, and dyspnea score. Patients and methods Randomized controlled design was used in this study. Patients recruited for this study were enrolled from the outpatient clinic of Department of Chest Diseases and Tuberculosis. Overall, 15 patients with stable COPD were enrolled in pulmonary rehabilitation group and underwent breathing exercises for 12 weeks. Moreover, 15 patients were enrolled in the control group. Statistical package for the social sciences (SPSS version 20) software was used for statistical analysis. Results In the breathing exercise group, there was a significant increase in the mean forced expiratory volume in first second (P = 0.001), forced vital capacity (P = 0.001), and inspiratory capacity (P = 0.015). There was a significant decrease in the mean functional residual capacity (P = 0.005), residual volume (P = 0.001), and total lung capacity (P = 0.001). There was no significant difference between the values of the previous parameters in the control group. Conclusion In stable COPD, breathing exercises improved pulmonary function parameters, 6-min walk distance, and dyspnea score.
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Bronchial asthma: clinical phenotypes and endotypes and their relation with glucocorticoids circadian rhythm and parasympathetic activity p. 154
Magdy M Zedan, Magdy Abd El Moneim El-Ziny, Abd Elazeez Atallah Shabaan, Youssef M Mosaad, Wafaa Nabil Laimon
DOI:10.4103/ejb.ejb_8_17  
Introduction Asthma is a heterogeneous disease and presents in different clinical patterns ‘phenotypes’ as a result of diverse pathobiological background ‘endotypes’. Objectives The aim of this study was to study serum interleukin-13 (IL-13) levels and the frequency of (IL-13) +1923C/T gene polymorphism in Egyptian children with asthma and to study glucocorticoids circadian rhythm in nocturnal asthma. Patients and methods The frequency of (IL-13) +1923C/T gene polymorphism genotypes was determined in 114 asthmatic Egyptian children and compared with a matched group of 152 healthy controls using PCR. Serum IL-13 and cortisol a.m. and p.m. concentrations in serum were assessed using enzyme linked immunosorbent assay. Results Serum IL-13 was found to be significantly higher in asthmatic patients when compared with the control group (P<0.0001). In the asthmatic group, forced expiratory volume in 1 s showed a significant negative correlation with serum IL-13 (ρ=−0.2, P=0.03), whereas peripheral blood eosinophilic % showed a significant positive correlation with serum IL-13 (ρ=0.18, P=0.05). No statistically significant differences were found between asthmatic patients and controls in IL-13 C1923T genotype frequency. A significantly lower serum cortisol pm was found in asthmatic patients with nocturnal symptoms when compared with those without nocturnal symptoms (P<0.0001). Conclusion Serum IL-13 is significantly higher in asthmatic patients when compared with controls. (IL-13) +1923C/T gene polymorphism is not a risk factor for development of asthma in Egyptian children. Nocturnal symptoms in some asthmatic patients can be partly attributed to lower serum cortisol level at night.
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Correlation between serum periostin biomarker, spirometric airflow limitation, and airway dimensions by multidetector computed tomography in bronchial asthma p. 160
Eman R Al-Adawy, Ashraf A Gomaa, Ahmed M Mohamed
DOI:10.4103/ejb.ejb_3_18  
Background Periostin has shown to be involved in the many aspects of allergic inflammation, such as acceleration of allergen-induced eosinophil recruitment, development of a Th2 phenotype, increased expression of inflammatory mediators, and airway remodeling and fibrosis in bronchial asthma and that fibrosis is one factor that causes steroid resistance or hyporesponsiveness in bronchial asthma. Aim This study aimed to evaluate the possible role of serum periostin as a biomarker for airway inflammation, for predicting the patient’s possible response to inhaled corticosteroids (ICS) after its regular use and its correlation with disease severity and control compared with functional and radiological findings. Patients and methods Sixty nonsmoker, asthmatic patients of at least 20 years of age and 20 control healthy nonsmokers with matched age and sex were included. Patients were then subclassified into two: first, according to the asthma severity into mild, moderate, and severe and then according to asthma control (controlled, poorly controlled, and uncontrolled). Serum periostin, spirometry, and multidetector computed tomography were performed for all included populations. Results There was significant statistical direct relation with increased serum periostin level and wall area and bronchial wall thickening (BWT) with asthma severity and all showed high significant increase among patients with uncontrolled than those with controlled asthma. Highly significant statistical direct correlation was found between BWT and serum periostin level. There was highly statistically significant decreased serum periostin level and BWT among the steroid-treated group of patients than in steroid-naive asthma (nonsteroid treated group of patients) which were significantly decreased after regular daily use of ICS for 6 months and also among uncontrolled patients after being adequately controlled than their baseline states. Conclusion Serum periostin marker and BWT had a significant, sensitive, accurate clinically relevant indicative value (especially when combined) as regards asthma control and severity and probable adequate response to ICS. Serum periostin not only could be a reliable biomarker for eosinophilic inflammation but also may contribute to the development of airway remodeling as assessed by multidetector computed tomography.
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Relationship between platelet count, platelet indices, and inflammatory markers in stable and acute exacerbation of bronchiectasis patients p. 173
Burcu A Yigitbas, Sibel Yurt, Berat Uslu, Celal Satici, Pelin Uysal, Ayse F Kosar
DOI:10.4103/ejb.ejb_62_17  
Background and objective Persistent and chronic infection is one of the reasons underlying the sustained inflammation in bronchiectasis patients, and inflammatory markers may possess important clinical implications in the follow-up. Platelets are known to have effects on inflammatory response; in addition, a negative correlation has been shown between mean platelet volume (MPV) and inflammatory disease activity. The objective of this paper is to investigate and compare the levels of platelet (PLT) count and platelet indices during stable and acute exacerbation of bronchiectasis patients. Patients and methods Data were retrospectively collected from medical files of 63 patients (39 women) and 29 controls without bronchiectasis. Thirty patients had an acute exacerbation, and 33 were in a stable state of disease. Descriptive data, clinical, radiologic, and laboratory information were noted. The relationship between inflammatory markers and pulmonary function tests was evaluated. Results White blood cell (WBC) count, C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), and PLT count were significantly higher; however, hemoglobin level and MPV were lower during exacerbation. There was a correlation between PLT and CRP, WBC, and ESR, and a negative correlation between PLT and forced vital capacity and forced expiratory volume in 1 s. However, we found an inverse correlation between MPV and WBC, and ESR, a positive correlation between MPV and forced expiratory volume in 1 s. Conclusion We have found that platelet indices PLT and MPV were significant in exacerbation of bronchiectasis patients compared with stable and control patients. Cell blood count, compared with CRP and other inflammatory markers, is a more practical, useful, cost-effective laboratory examination. Not just looking at the WBC, but just taking a glance at the platelet indices would be a useful and simple way to evaluate bronchiectasis patients.
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Clinical phenotype as a predictor of outcome in mechanically ventilated chronic obstructive pulmonary disease patients p. 180
Alaa Eldin Metwally Mohamed Elgazzar
DOI:10.4103/ejb.ejb_71_17  
Background The outcome in patients with chronic obstructive pulmonary disease (COPD) who need mechanical ventilation (MV) is altered by several factors such as severity of the disease, severity of acute exacerbation, advanced age, the cause of exacerbation, and development of complications. Aim This study aimed to assess the outcome of clinical phenotypes of MV COPD patients who were admitted to the respiratory ICU in 2014 and the influencing factors. Patients and methods This prospective study included 106 MV COPD patients. All patients underwent a thorough medical history, routine and specific investigations including: chest radiography, high-resolution computed tomography, serum immunoglobulin E, total and differential leukocytic count, serial arterial blood gases immediately before intubation, during MV and just before weaning. Results There were many predictors of bad outcome with statistical significance such as: older age (62.94±12.5 vs. 57.81±12.6 years), higher temperature on admission (37.48±0.67 vs. 37.20±0.42°C), higher serum of HCO3 on admission (42.5±4.5 vs. 38.9±7.8 mEq/l), longer duration of MV (12.05±4.4 vs. 4.8±1.84 days), higher last year number of exacerbations (1.94±0.9 vs. 1.47±0.6 times), with shorter duration from last exacerbation (40.4±1.2 vs. 50.5±2.04 days), dyspnea as the main presenting symptom, past history of MV, occurrence of complications during MV, emphysema phenotype (52.7 vs. 22.8%). Conclusion Past history of MV, emphysema phenotype, duration of MV, higher last year number of exacerbations, and shorter duration since the last exacerbation are reliable predictors of poor outcome and mortality in MV COPD patients with acute on top of chronic respiratory failure.
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Assessment of the prevalence of depression in chronic obstructive pulmonary disease patients p. 187
Sherif A Eissa, Tarek S Essawy, Mohammad A Almahdy, Shaymaa A Mohammed, Mohammed M El-Hamady
DOI:10.4103/1687-8426.233048  
Background Depression often occurs in patients with chronic obstructive pulmonary disease (COPD). In stable COPD, the prevalence of clinical depression ranges between 10 and 42%. The risk of depression is higher in patients with severe COPD, compared with control participants, reaching up to 62%, in oxygen-dependent patients. Aim The aim of this work was to study the prevalence of depression in COPD patients. Patients and methods The present study was carried out on 100 male COPD patients and 10 female COPD patients admitted to Mansoura Chest Hospital and the chest department of Benha University Hospital during the period from 2014 to 2016. All participants were submitted to Beck’s depression Inventory questionnaire. Results The degree of depression assessed by Beck’s score increased significantly with the degree of COPD, use of long-term oxygen therapy, and low BMI. Conclusion The prevalence and severity of depression increase with increasing severity of COPD.
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ORIGINAL ARTICLE: BRONCHOSOCOPY & INTERVENTIONAL PULMONOLOGY Top

Impact of a designed educational program on elderly patients undergoing flexible bronchoscopy p. 193
Ali A Hasan, Anwar M Ali, Soad A Sharkawy, Hanan A Abozeid, Martha M Labieb
DOI:10.4103/ejb.ejb_55_17  
Background Bronchoscopy is a frequently required procedure in the elderly due to the high prevalence of pulmonary diseases. Bronchoscopy is associated with fears, stress, and anxiety. Aim To evaluate the impact of an educational program on patient knowledge, anxiety level, difficulties, duration, and complications of bronchoscopy procedure in elderly patients. Patient and methods One hundred and fifty patients aged 60 years and older candidates for bronchoscopy were included. The patients were randomly divided into two equal groups: 75 patients received educational guideline (study group); 75 patients did not receive educational guideline (control group). Patient knowledge about bronchoscopy and anxiety level were assessed. The esigned educational program was applied to the study group on the day before the procedure. It included brochures with simple and brief instructions and pictures about bronchoscopy in Arabic language. It also includes the structure of the respiratory system, definition, indications and complications of bronchoscopy, patient preparation before, during and after the procedure, and patient’s precautions that should be taken during and after bronchoscopy. Results There were insufficient knowledge and high anxiety scale about bronchoscopy. Knowledge score significantly increased and anxiety scale significantly decreased after providing the patients with educational program (P<0.001 for each). There was significant reduction in the duration of bronchoscopy procedure and the amount of anaesthesia used in the study than in the control group (P<0.001). Difficulties and discomfort were significantly lower in the study group. Conclusion Besides improving knowledge and reducing anxiety score, implementing the designed educational program increases tolerability, easiness and decrease problems related to bronchoscopy.
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ORIGINAL ARTICLES - CRITICAL CARE Top

Study of plasma copeptin level as a prognostic marker in respiratory failure patients admitted in the ICU at Benha University Hospital p. 200
Mahmoud M Al Salahy, Mohammad A Elmahdy, Tahany M Gouda, Khaled M Belal, Shiemaa M Elnahas
DOI:10.4103/ejb.ejb_7_17  
Background Arginine vasopressin (AVP), produced by hypothalamic neurons, is released during stress following different stimuli such as hypotension, hypoxia, hyperosmolarity, acidosis, and infections. Measurement of AVP levels has limitations because of its short half-life and instability. Copeptin, the carboxy-terminal part of the precursor (prepro-AVP), is a more stable peptide and mirrors AVP concentrations. Aim The aim of this work was to study the usefulness of plasma copeptin as a predictor of prognosis and outcome of respiratory failure patients admitted in the ICU. Patients and methods This prospective study was carried out on 45 patients (38 patients admitted at Benha University Hospital ICU and Chest Department and seven healthy patients). They were classified into three groups: group A (ICU patients) comprised 30 patients admitted with respiratory failure due to different chest diseases; group B (in-patients) comprised eight patients selected from those hospitalized at Chest Department because of respiratory failure and with no need for ICU admission as a positive control group; and group C comprised seven healthy patients included as a negative control group. All patients were submitted to full clinical history and physical examination at ICU admission, as well as available preadmission clinical data, pulmonary function tests, chest radiography if done, arterial blood gases, ECG, and clinical lab data; blood samples were taken and plasma was separated and copeptin level was measured by sandwich immunoluminometric assay. Results There was a statistically significant difference among studied groups as regards plasma copeptin level, which was higher in ICU patients (group A) than in in-patients (group B) and healthy control patients (group C) (P<0.001). There was a statistically significant correlation between copeptin level and both Glasgow Coma Scale and Acute Physiology and Chronic Health Evaluation II (APACHE II) score (P<0.001). The relation with Glasgow Coma Scale was negative, whereas that with Acute Physiology and Chronic Health Evaluation II score was positive. There was a statistically significant positive correlation between mean copeptin level and patients’ outcome, as its level was markedly higher in nonsurvivors (80.6+31.6) than in survivors (30.5+17.3) (P<0.001), substantiating it as a prognostic marker in critically ill patients. In ICU patients copeptin levels less than 55 pg/ml predict good prognosis and survival among ICU patients, with a sensitivity of 88.2% and a specificity of 84.6%. Conclusion Elevated plasma copeptin levels reflect disease severity and predict short-term mortality. Copeptin concentrations are strongly related to hypoxia, as they increase markedly with low blood oxygen concentration. Elevated plasma copeptin levels predict long hospital and ICU stay. Plasma copeptin levels increased progressively with the development of complications in ICU patients.
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Validity of three scoring systems in assessing the severity and outcome in Al-Abbassia Chest Hospital Respiratory Intensive Care Unit patients p. 208
Taher Abd El-Hamid El-Naggar, Riham H Raafat, Safaa A Mohamed
DOI:10.4103/ejb.ejb_81_17  
Background ICU scoring systems allowed an assessment of the severity of disease and death prediction. As ICU populations, investigations and management were changed, scoring systems should be updated. Aim The aim of this study was to evaluate three scoring systems in predicting outcome in Al-Abbassia Chest Hospital Respiratory ICU patients in 6 months. Patients and methods It was conducted on newly admitted cases in Al-Abbassia Respiratory ICU from July 2016 till January 2017. All patients were evaluated on admission and after 48 h by Acute Physiology and Chronic Health Evaluation IV (APACHE IV), Sequential Organ Failure Assessment (SOFA), and Simplified Acute Physiology Score II (SAPS II). Results APACHE IV and SAPS II scores were significantly higher between dead than alive patients on admission and after 48 h, but were not able to predict death in ICU. SOFA score was insignificantly higher on admission and after 48 h between nonsurvivors. None of the three scores could predict the length of stay in ICU. Conclusion APACHE IV and SAPS II scores were better than SOFA score as they were significantly higher between nonsurvivors but not to the extent to predict mortality or length of stay.
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Assessment of ventilator-induced diaphragmatic dysfunction in patients with chronic obstructive pulmonary disease using transthoracic ultrasonography p. 218
Shereen Farghaly, Ali A Hasan, Hoda A Makhlouf
DOI:10.4103/ejb.ejb_99_17  
Background Mechanical ventilation (MV) can cause progressive thinning of diaphragm muscle and hence progressive decrease in diaphragmatic function. We aimed to assess the rate at which diaphragm thickness (tdi) changed during MV and its effect on weaning outcome using transthoracic ultrasound (TUS) evaluation in patients with chronic obstructive pulmonary disease (COPD). Patients and methods Thirty mechanically ventilated patients with COPD were enrolled in this cohort study. Baseline tdi was recorded within 24 h of MV after stoppage of sedation using TUS. The subsequent measurements were recorded on the third, fifth, and seventh day of MV and at the time of initiation of weaning. Results There was a significant decrease in tdi at end expiration and at end inspiration by approximately 27.2 and 17% at third day of MV, respectively, and 35.5 and 18.5% at fifth day of MV, respectively, compared with baseline parameters. In the 10 patients who were still on ventilator till the seventh day, tdi were significantly lower compared with baseline recordings. Percentage of decrease of tdi at end inspiration from baseline recordings was significantly higher in patients with difficult weaning than in those with simple weaning. The optimum cutoff value of % of decline of tdi at end inspiration associated with difficult weaning was at least 10.6% giving 88.9% sensitivity and 83.3% specificity. Conclusion MV is associated with gradual diaphragmatic atrophy which can be detected by TUS and could predict weaning outcome in mechanically ventilated patients with COPD.
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ORIGINAL ARTICLE - INTERSTITIAL LUNG DISEASES Top

Prognostic factors and outcome of mechanically ventilated interstitial lung disease patients p. 226
Ashraf Zin El-Abdeen, Lamiaa H Shaaban, Shereen Farghaly, Yara Y Omar
DOI:10.4103/ejb.ejb_101_17  
Background The prognosis of mechanically ventilated interstitial lung disease (ILD) patients was controversial in previous studies. Identifying the factors associated with mortality could guide therapy and allow good use of ICU resources. Aim The aim was to study the outcome of ILD mechanically ventilated patients admitted to the respiratory ICU and to demonstrate the possible factors associated with mortality in these patients. Patients and methods The observational prospective study was carried out on ILD patients undergoing mechanical ventilation, either invasive mechanical ventilation (IMV) or noninvasive ventilation (NIV). Clinical, radiological, and outcome assessments were done for all enrolled patients. For outcome assessment, patients were classified into either survivors or nonsurvivors. Results Twenty-one (70%) of the patients were subjected to NIV, whereas nine (30%) of them were subjected to IMV. The overall mortality rate was 53.3%. However, the mortality rate was 35% in patients with NIV, but 100% in patients with IMV. Severity assessment scores were significantly higher in nonsurvivors compared with survivors. Nonsurvivors also presented significantly with lower pH and higher PaCO2 compared with survivors. Acute Physiology and Chronic Health Evaluation-II score greater than or equal to 18.5, Simplified Acute Physiology Score greater than or equal to 27.5, Glasgow coma scale score less than 12.5 and PaO2/FiO2 less than 161.5 were associated with increased risk of mortality of ILD patients. Conclusion Mechanically ventilated ILD patients had a poor outcome. However, the survival rate of ILD patients was better on NIV than IMV. Severity assessment scores and PaO2/FiO2 could predict the risk of mortality in ILD patients.
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ORIGINAL ARTICLES: MISCELLANEOUS Top

Pulmonary complications within the first year after bone marrow transplantation p. 233
Amal Abd El-Azem Sadon, Rehab S El-Hagrasy, Mohamed A Saraya
DOI:10.4103/ejb.ejb_33_17  
Background Pulmonary complications (PCs) are a significant cause of morbidity and mortality in hematopoietic stem cell transplant (HSCT) recipients. Pulmonary infiltrates in such patients pose a major challenge for clinicians because of the wide differential diagnosis of infectious and noninfectious conditions. It is rare for the diagnosis to be made by chest radiograph, and commonly these patients will need further invasive and noninvasive studies to confirm the etiology of the pulmonary infiltrates. Aim The aim of this research was to study the pattern of lower respiratory tract infection within the first year after HSCT. Patients and methods This is a prospective study of 60 patients receiving HSCT (because of hematological and nonhematological malignancy) at Kuwait Cancer Center within the first year after transplantation for any suspicious respiratory tract infection. Patients were subjected to sputum and blood examination along with bronchoscopic examination and bronchoalveolar lavage if indicated, and all samples were subjected to microbiological examination for diagnosis of the causative organism. Results Sixty patients were studied for PCs either infectious or noninfectious within the first year after HSCT. The most common complications were infectious complications (70%). Severe PCs were the main causes of death in 13 (21.6%) cases. The PCs were more common and recurrent in allogeneic bone marrow transplantation (BMT) recipients, in whom PCs contributed to death in 12 cases. Bacterial infection, pulmonary edema, and diffuse alveolar hemorrhage were seen more in the early post-BMT period (<100 days), whereas viral, fungal infection, graft-versus-host disease, and bronchiolitis obliterans were seen more in the late post-BMT period (>100 days). Conclusion Lower respiratory tract infection is a serious complication after BMT transplantation. Mixed bacterial and opportunistic infections are the most common etiologies. Pulmonary infiltrates in such patients pose a wide differential diagnosis of infectious and noninfectious conditions. PCs are a significant causes of death in BMT recipients.
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Neighbours affect each other; pulmonary affection after cardiac surgery p. 240
Reham M Elkolaly, Mohab Sabry, Mohamed Abo-Elnasr, Amr Arafat
DOI:10.4103/ejb.ejb_57_17  
Introduction Lungs and heart are in close relation all the time; they affect each other. Pulmonary complications due to cardiac surgeries may alter the surgery outcome and patient survival. Aim The aim of this study was to report the most frequent respiratory complications after cardiac surgeries. Materials and methods The study included 22 patients (group 1) who underwent coronary artery bypass grafting and 56 patients (group 2) who underwent valve replacement surgery. Preoperative and postoperative investigations such as chest radiology, spirometric lung functions and PaO2/FiO2 were performed. Pleural effusion, pneumothorax, acute respiratory distress syndrome, pneumonia, atelectasis, wound infection or sternal dehiscence were reported. Results Pleural effusion, pneumothorax, acute respiratory distress syndrome, pneumonia, atelectasis, and sternal wound infection in group 1 were found among 81.81, 4.55, 9.10, 31.82, 86.36 and 18.18% of the included patients, respectively, whereas in group 2 they were found among 33.93, 0, 0, 35.71, 64.29 and 10.71%, respectively. Conclusion Complications after cardiac surgeries are common and precautions must be taken to decrease them and to improve outcome.
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ORIGINAL ARTICLES: PLEURAL DISEASE Top

Prevalence, causes, and clinical implications of pleural effusion in pulmonary ICU and correlation with patient outcomes p. 247
Mohamed Farrag, Ahmed El Masry, Amr M Shoukri, Mona ElSayed
DOI:10.4103/ejb.ejb_117_17  
Introduction Pleural effusion is common in medical ICU (MICU) patients, and it may develop owing to different causes and may affect patients outcomes. Objective The aim of this work was to study the prevalence and causes of pleural effusion in MICU and its effect on patient outcomes. Patients and methods A total of 90 patients admitted to MICU in Abbaseia Chest Hospital were included in the present study. The patients initially had pleural effusion or effusion developed during their ICU stay. Results Overall, 66 patients were males and 24 were females, and their mean age was 51.5±18.6 years. The prevalence rate of pleural effusion in our MICU during 1-year period was 12.7%. Pleural effusion was found to be exudates in 77.7% of cases and transudates in 22.3%. Uncomplicated parapneumonic effusion was the most common cause (36.7%), followed by heart failure (17.8%). The cause of pleural effusion did not significantly affect the patient outcome or duration of ICU stay. No significant reduction in duration of ICU stay or ICU mortality was seen in patients who received therapeutic aspiration or tube drainage compared with patients who received no specific management for effusion. Conclusion The commonest cause of pleural effusion in MICU is parapneumonic effusion, and chest ultrasonography is the best method of fluid detection. Different methods of management do not significantly affect patient outcomes.
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Study of pleurodesis using ethanolamine oleate through ultrasound-guided pigtail p. 253
Adel M Saeed, Tamer M Ali, Ashraf A Gomaa, Mohamed N Kamel
DOI:10.4103/ejb.ejb_78_17  
Background Malignant pleural effusion (MPE) is a common and serious condition that is associated with poor quality of life, morbidity and mortality. Aim Study of pleurodesis using ethanolamine oleate (ETH) through ultrasound-guided pigtail to evaluate the efficacy and complications of ETH and pigtail. Design Thirty-three patients with MPE were included and were subjected to history taking, clinical examination, chest radiographs (on admission, every day before pleurodesis to ensure complete lung expansion and to exclude pneumothorax, every day after pleurodesis till the removal of the catheter and on follow-up − 2 months after pleurodesis − to check for reaccumulation of pleural effusion), chest sonography, pleural tapping, chest computed tomography scan (in some patients), pleural biopsy using Abram’s needle or through ultrasonography (in some cases), lymph node biopsy (in some cases) and spirometry before and 2 months after pleurodesis. Patients were subjected to pigtail catheter insertion using chest sonography. When the amount of effusion became less than 100 ml/day and when the chest radiography shows complete lung expansion and there is no evidence of bronchopleural fistula, pleurodesis with ETH was done. Then after 12 h, the pigtail was connected to a drainage device. Follow-up radiographs were done every day till the removal of the catheter. When the amount of the effusion became less than 100 ml/day, the catheter was removed. Assessment of the response was made after 2 months of pleurodesis, before death that may occur to the patient within 3 to 12 months after diagnosis. Despite the progress in cancer treatment, the management of MPE remains palliative, with median survival ranging from 3 to 12 months. Results Complete response was 81.8% of studied cases, while no/partial response was 18.2%. Pleurodesis complications were fever (21.1%), chest pain (33.3%), nausea (24.2%), vomiting (12.1%) and hypotension (6.1%). Pigtail complications were pigtail obstruction (3.03%), chest pain (3.03%) and obstruction and pain (12.12%) of the studied cases. There was a decrease in FVC% and FEV1% 2 months after pleurodesis. However, no significant difference as regards actual (measured) FEV1/FVC% before and 2 months after pleurodesis in all cases. Whereas, complete response was 81.8% by CXR and chest ultrasound. Conclusion ETH injection through pigtail was safe and effective in pleurodesis of MPE.
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Role of transthoracic ultrasound in differentiation of the causes of pleural thickening p. 260
Khaled M Kamel, Yasmine H El-Hinnawy
DOI:10.4103/ejb.ejb_109_17  
Objectives Pleural thickening is defined as the increase in thickness of the pleura of more than 3 mm and can be caused by a wide range of diseases, either nonmalignant or malignant. Thoracic ultrasound has high sensitivity in assessing the pleura. Aim The aim of this study was to assess the role of thoracic ultrasound in differentiation of the causes of pleural thickening. Design A prospective study included 48 patients selected from the inpatient Chest Department, Kasr Al-Ainy Hospital, from January 2016 till October 2017. Patients diagnosed as having pleural thickening underwent thoracic ultrasound as well as ultrasound-guided pleural biopsy by Tru-cut needle. Descriptive data were obtained including age and sex of the patients. Thoracic ultrasound was done for the side of pleural thickening. The distribution of pleural thickness, either localized or diffuse; the surface; invasion of chest wall or diaphragm; the echogenicity and vascularity; and the presence of pleural effusion and its pattern were determined. The patients were classified into two main groups: nonmalignant (subclassified as tuberculous and nonspecific infection) and malignant cases (subclassified as mesothelioma and metastatic cases). Results There was a statistically significant relation between the distribution either localized, diffuse, unilateral, or bilateral; the surface of the thickness; invasion of chest wall or diaphragm; the echogenicity; vascularity of the pleural thickness; and the presence of pleural effusion and its pattern on one hand and the diagnosis of pleural thickening on the other hand. There was insignificant statistical difference between pleural mesothelioma and pleural metastatic cases, and also there was insignificant statistical difference between tuberculous and nonspecific infection cases. Conclusion The transthoracic ultrasound had a very good predilection for the diagnosis of pleural thickening etiology whether malignant or nonmalignant.
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ORIGINAL ARTICLE - PULMONARY INFECTION Top

Workplace pulmonary tuberculosis case detection in Mansoura City and neighborhood villages p. 266
Samah S El Hadidy, Sohair F El-Bestar, Emily A Kamel, Nesrein M Shalabi
DOI:10.4103/ejb.ejb_54_17  
Context Tuberculosis (TB) represents a high burden in workplaces. Aims Therefore, the aim of this study was to detect pulmonary TB cases in the workplace and assess the associated risk factors. Settings and design This cross section study was carried out from January 2011 to December 2013. This study included 253 participants recruited from Mansoura City and neighborhood villages Dakahlia Governorate. The catchment areas and occupational categories were determined according to a 1-year retrospective study reviewing hospital records. Participants and methods All participants were subjected to the following: (a) assessment of sociodemographic data, occupational data, and risk factors for TB. (b) Clinical examination. (c) Screening by chest radiography, the tuberculin skin test, and sputum Ziehl–Neelsen stain. (d) Assessment of knowledge of TB. Data were analyzed using statistical package for the social sciences, version 15. Qualitative data were presented as number and percentage. Comparison between groups was carried out using the χ2-test. Results Most participants were younger than 35 years of age, men, smokers, married, and with low educational and monthly income. Silica-related occupations were the most common. History of Bacillus Calmette–Guérin vaccination was not found among TB participants and was found in only 8.9% of non-TB participants. The majority of participants reported 8 working hours with no use of protective tools. The TB participants had significantly lower knowledge scores than nontuberculous participants. A total of 136 out of 148 participants had a positive tuberculin skin test. Chest radiography indicated an abnormality in six out of 253 participants and five of these were positive for sputum Ziehl–Neelsen. Conclusion TB screening in workplaces is mandatory because it can identify asymptomatic cases with active TB. A poor knowledge score may be considered a risk factor for TB infection in the workplace.
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CASE REPORT Top

Unilateral lung hyperlucency in an adult: an unusual cause p. 273
Parul Kodan, Abanti Das, Surabhi Vyas, Animesh Ray, Surinder K Sharma
DOI:10.4103/ejb.ejb_72_17  
We report a case of young adult with unilateral lung hyperlucency. His radiological features were suggestive of Swyer–James syndrome. The condition is uncommon in adults. We report this rare case with discussion on clinical presentation, diagnosis, and management of Swyer–James syndrome. The report also throws light on various other causes of unilateral lung hyperlucency and its approach.
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LETTER TO EDITOR: AIRWAY DISEASES Top

Pulmonary function tests in patients with chronic rhinosinusitis and the effect of surgery p. 276
Mahmood D Al-Mendalawi
DOI:10.4103/ejb.ejb_69_17  
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