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   Table of Contents - Current issue
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July-September 2018
Volume 12 | Issue 3
Page Nos. 279-372

Online since Monday, August 20, 2018

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ORIGINAL ARTICLES - AIRWAY DISEASES  

Outcome of pulmonary rehabilitation in patients with stable chronic obstructive pulmonary disease at Chest Department, Zagazig University Hospitals (2014–2016) p. 279
Samah M Shehata, Monzer M Refky, Maha M Al gabry, Ramadan M Nafae
DOI:10.4103/ejb.ejb_21_18  
Context Chronic obstructive pulmonary disease (COPD) is a very disabling disorder that is accompanied by some extrapulmonary manifestations. Pulmonary rehabilitation (PR) is outlined to enhance both physical and psychological condition of patients with chronic chest diseases. Aims We aimed at evaluating the effectiveness of 8 weeks of outpatient PR on improving breathlessness, quality of life, exercise tolerance, and functional ability in patients with stable COPD. Settings and design A randomized controlled clinical study was conducted. Patients and methods The current study was carried out on 80 patients with stable COPD who were classified into group 1, where 40 patients were subjected to usual pharmacological therapy for COPD and PR for 8 weeks, and group 2, where 40 patients were subjected to usual pharmacological therapy only. Both groups were assessed regarding spirometric pulmonary function, arterial blood gases, 6 min walk test, dyspnea score (modified-Medical Research Council), and health-related quality of life [Saint George respiratory questionnaire (SGRQ)]. SPSS 20.0 for windows and MedCalc 13 for windows were used for statistical analysis. Results Approximately 50% of patients in group 1 showed improvement in dyspnea, whereas only 25% of patients were improved in group 2. Moreover, there was a statistical significance difference between both patient groups regarding the post-treatment improvement in 6 min walk distance (6MWD) and the post-treatment improvement in the three components of SGRQ score and also in the total SGRQ score (P<0.001). The improvement in 6MWD showed significantly inverse correlation with the baseline age, modified-Medical Research Council, and SGRQ scores, whereas the improvement in 6MWD was significantly directly correlated with the baseline forced expiratory volume in 1 s, forced expiratory volume in 1 s/forced vital capacity, PaO2, and baseline 6MWD. Conclusion PR for patients with stable COPD is an effective tool for improving quality of life, exercise capacity, and dyspnea score.
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Evaluation of health-related quality of life in patients with chronic obstructive pulmonary disease p. 288
Taghreed S Farag, Eman S.M Sobh, Sawsan B Elsawy, Bardees M Fahmy
DOI:10.4103/ejb.ejb_11_18  
Introduction The quality of life plays an important role in chronic disease management, including chronic obstructive pulmonary disease (COPD). Objective To assess the quality of life in COPD patients and its relationship to disease severity. Patients and methods Two hundred Egyptian COPD patients were included in the study. We collected demographic data, comorbidities, dyspnea score, and other symptoms. Spirometry, 6-min walk tests were also conducted. Health-related quality of life (HRQoL) assessment was done with the Arabic version of St George’s Respiratory Questionnaire. Results There was male predominance (72%); in most of the cases (79%), there were more than 50 years old. COPD patients who had significantly reduced HRQoL. Age, frequency of exacerbations per year, comorbidity, particularly hypertension and ischemic heart disease, modified Medical Council Research Dyspnea scale dyspnea scale, BODE index, GOLD spirometric staging, and New GOLD stage showed significant positive correlation with St George’s Respiratory Questionnaire. Lower spirometric parameters, 6-min walk tests, and SpO2%, were correlated with impaired HRQoL. Conclusion Patients with COPD had reduced HRQoL. Frequent exacerbations, advanced airway obstruction, and dyspnea severity had negative impact on HRQoL.
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Diagnostic value of 8-isoprostane and transforming growth factor-β in bronchial asthma patients p. 295
Amgad Frahat, Yousef Mansour, Ayman Eldib, Doaa Alsed
DOI:10.4103/ejb.ejb_18_17  
Background Asthma is an airway inflammatory disease with functional and structural changes, leading to bronchial hyperreponsiveness and airflow obstruction. 8-Isoprostane (8-iso-PGF2α) is considered a marker of oxidative stress specific to lipid peroxidation, transforming growth factor β1 (TGFβ1) as an important fibrogenic and immunomodulatory factor known to induce structural changes associated with asthma. Objective We aimed to study the diagnostic value of 8-iso-PGF2α and TGFβ1 in asthmatic patients. Patients and methods Samples of serum and bronchoalveolar lavage fluid from 40 asthmatic patients (20 moderate and 20 severe) and 10 healthy volunteers were assessed for their levels of 8-iso-PGF2α and TGFβ1. Results Bronchoalveolar lavage 8-iso-PGF2α and TGFβ1 was higher in asthmatic patients. It was significantly increased with increased asthma severity. Conclusion Increased levels of TGFβ1 and 8-iso-PGF2α is associated with disease severity. However, there is need for continued exploration on the mechanisms responsible for these structural changes.
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Chronic obstructive pulmonary disease exacerbations and periodontitis: a possible association p. 303
Hesham A AbdelHalim, Heba H AboElNaga, Reham L Aggour
DOI:10.4103/ejb.ejb_12_18  
Background There is an increasing interest concerning the potential link between both chronic obstructive pulmonary disease (COPD) and chronic periodontitis; therefore the association became the research focus. Objective This study intended to evaluate the potential association between the frequency of COPD exacerbations and chronic periodontitis. Patients and methods A total of 250 male patients with COPD were included in the study and were categorized into two groups according to the frequency of exacerbations per year: group 1 had patients with frequent exacerbations (having ≥2 exacerbations in last year) and group 2 had patients with infrequent exacerbations (having <2 exacerbations in last year). They were compared regarding age, smoking history, education background, information of their oral hygiene behaviors, calculated modified Medical Research Council dyspnea scale, calculated COPD assessment test, the number of exacerbations and hospitalizations in the past year, prebronchodilator and postbronchodilator spirometry, calculated plaque index, bleeding index, probing pocket depth, clinical attachment level, and measured high-sensitivity C-reactive protein. Correlations between variables were examined. Logistic regression test was performed to explore the concurrent influences of periodontal health variables on the frequency of exacerbations. Results This study evidenced that all periodontal health variables were significantly correlated with smoking status, modified Medical Research Council dyspnea scale, COPD assessment test, number of exacerbations and hospitalizations per year, and C-reactive protein level. Simplified oral hygiene index, plaque index, bleeding index, gingival index, probing pocket depth, and clinical attachment level were significantly correlated with most of the spirometry data. Conclusion Periodontal health variables were considerably associated with the frequency of COPD exacerbations.
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Outcome of short-term systemic steroid therapy in chronic obstructive pulmonary disease patients with acute exacerbation p. 310
Ashraf Zin El-Abdeen, Lamiaa H Shaaban, Shereen Farghaly, Hanan Galal, Entsar H Mohammed
DOI:10.4103/ejb.ejb_104_17  
Background There are insufficient data on the optimum duration of systemic steroid therapy during acute exacerbation of chronic obstructive pulmonary disease (COPD). Aim To evaluate the outcome of short-term systemic steroid therapy in patients hospitalized with acute exacerbation of COPD and to identify factors associated with treatment failure. Patients and methods Fifty severe and very severe COPD patients with acute exacerbation were consecutively included in this study. Patients were assessed by a clinical symptom score, peak expiratory flow rate (PEFR), arterial blood gases and laboratory investigations [blood count indices, high sensitive C-reactive protein, erythrocyte sedimentation rate (ESR) and fibrinogen level]. Short-term systemic steroids were initiated and the outcome was assessed at day 5 of therapy and the patients were classified into treatment success group or failure group. Results Treatment failure was observed in 27 (54%) of patients. Patients with treatment failure had significantly higher cough and chest tightness scores, higher partial pressure of CO2 in arterial blood (PaCO2), lower partial pressure of O2 in arterial blood (PaO2), lower PEFR, higher red distribution width (RDW), and higher ESR compared with the success group. By binary logistic regression, higher PaCO2, lower PaO2, and higher ESR were independent risk factors associated with treatment failure. The optimum cutoff level of PaCO2, PaO2, and PEFR associated with treatment failure was more than or equal to 59.5 mmHg, up to 43.5 mmHg, and up to 225 l/min, respectively. ESR first hour of at least 35 and RDW of at least 15.5% were also associated with treatment failure. Conclusion Most severe and very severe COPD during acute exacerbations need prolonged course of systemic steroids (>5 days). Clinical evaluation, gasometric parameters, PEFR, RDW, and ESR could be good predictors of treatment failure on short-term systemic steroid.
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Low-level laser therapy in chronic obstructive lung disease p. 317
Mahmoud A Sayed, Rania M El-Sherif, Amany R Mohamed, Ahmed A El-Sherif
DOI:10.4103/ejb.ejb_110_17  
Context Chronic obstuctive lung disease (COPD) is a common preventable and treatable disease. Low-level laser therapy (LLLT) appears to be a promising modality in COPD management. Aims The aim was to study the short-term effects of LLLT on clinical and cardiac status in patients with stable COPD. Materials and methods This was a controlled randomized study. Patients with impaired left ventricular ejection fraction less than 50%, those with atrial fibrillation (AF), those with pulmonary hypertension not owing to COPD, and those with any contraindication to exercise test or LLLT were excluded. A total of 30 patients with stable COPD were divided into laser and control groups (15 patients each). Medical treatment was optimized in both groups with the addition of LLLT in the laser group. The following were assessed before and after LLLT: Modified Medical Research Council (mMRC) scale, 6 min walk test, tricuspid annular plane systolic excursion, and lateral tricuspid annulus tissue Doppler velocities. The LLLT has wavelength of 905 nm, output of 5–20 mW, and frequency of 500 Hz. Laser probe was placed on intercostal space both anteriorly and posteriorly on chest wall and arm with standardized laser acupuncture points of application with a frequency of five sessions/week for 2 successive weeks. Statistical analysis Statistical package for the social sciences Software program, version 21 (SPSS). Data were summarized using range, mean, SD, and median for quantitative variables and frequency and percentage for qualitative ones. Comparison between groups was performed using independent sample t-test (if parametric) or Mann–Whitney test (if nonparametric) for quantitative variables and χ2-test or Fisher’s exact test for qualitative ones. Paired quantitative measures were evaluated using paired t-test (if parametric) or Wilcoxon test (if nonparametric). P values less than 0.05 were considered statistically significant, and less than 0.01 were considered highly significant. Results Patients in LLLT group had higher pulmonary artery systolic pressure, lower early (E′) and higher late (A′) lateral tricuspid annular velocities by Tissue Doppler echocardiography (TDE) versus control. Overall, 100% of laser patients showed improvement in mMRC scale by at least one grade versus 46% in control. In laser group, 6 min walk test was 24.4±10.4 before versus 52.9±14.7 m at the end of the study (P=0.001). In control, it was 32.4±14.9 versus 40.1±19.2, (P=0.003). No echocardiographic changes were noticed before versus after the study. Conclusion Significant clinical improvement of 6 min walk test and mMRC scale grading after LLLT therapy was observed. No detrimental effects of LLLT on left ventricle or right ventricle functions or pulmonary artery systolic pressure were seen.
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ORIGINAL ARTICLES - CRITICAL CARE Top

Real-time tracheal ultrasonography for confirming endotracheal tube placement p. 323
Ahmed E Kabil, Ahmed M Ewis, Ahmed M Al-Ashkar, Mohamed A.A Abdelatif, Mohamed O Nour
DOI:10.4103/ejb.ejb_88_17  
Objective To evaluate the accuracy of tracheal ultrasonography for confirming the endotracheal tube placement during patients’ intubation. Patients and methods The current study was a prospective, randomized study performed at the ICU of Al-Hussein Hospital, Cairo. Intubated for respiratory failure, cardiac arrest or other medical causes were included in the current study. Real-time tracheal ultrasonography was conducted during intubation with the ultrasound probe placed transversely over the trachea above the suprasternal notch for confirming the tube position, either tracheal or esophageal. The standard method for confirming endotracheal tube placement include clinical evaluation and rapid bronchoscopic confirmation. The main outcomes were the degree of accuracy and timeliness of tracheal ultrasound in confirming endotracheal tube placement. Results Forty patients eligible for endotracheal intubation were randomized in the current study and only four (10%) patients had confirmed esophageal intubations. Our results concluded that tracheal ultrasound had a diagnostic accuracy of 97.5% in the detection of endotracheal tube site. The sensitivity was 97.2%, while the specificity was 100%. Tracheal ultrasound had a positive predictive value of 100%, while the negative predictive value was 80%. The total operating time of ultrasonography was significantly lower than that of bronchoscopy. Conclusion Real-time ultrasound of the trachea is an accurate, feasible, and fast method in confirming endotracheal tube placement.
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Outcomes and predictors of success of noninvasive ventilation in acute exacerbation of chronic obstructive pulmonary disease p. 329
Mostafa Shaheen, Rasha G Daabis, Hend Elsoucy
DOI:10.4103/ejb.ejb_112_17  
Background Noninvasive ventilation is appropriately used as a first-line treatment of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in many emergency departments. It has been evaluated in a large number of trials, often with clinically important benefits, but the use of noninvasive positive pressure ventilation remains highly variable across institutions and geographical regions. The aim of the study was first to emphasize the superiority of noninvasive ventilation (NIV) in acute hypercapneic respiratory failure in patients with an AECOPD in comparison with conventional therapy alone and second was to identify the predictors of NIV failure in such patients. Patients and methods A total of 50 patients were randomly allocated into two equal groups: 25 patients subjected to medical and oxygen therapy (group I) and 25 to medical and NIV (group II). All patients were followed until death or discharge. Results Group II had a success rate (for weaning and discharge) of 76%, whereas in group I, it was 20% (odds ratio=0.0789, 95% confidence interval=0.021–0.302 and P<0.001). Hospital stay was significantly longer in group I. Complications were significantly higher in group I. Mortality was significantly higher in group I. Improvement of arterial blood gases, respiratory rate, dyspnea scores and hypercarbic encephalopathy was significantly better in non-invasive positive pressure ventilation (NIPPV) group. Conclusion The addition of NIPPV to standard therapy confers more benefits in patients with AECOPD, with significant reduction of in-hospital mortality, rate of endotracheal intubation, incidence of complications and length of hospital stay compared with standard therapy alone. On the contrary, failure can be predicted by the presence of more comorbidities, signs of severe exacerbation, high BMI, high baseline blood sugar, rapid respiratory rate at admission, abnormal baseline renal functions, high baseline C-reactive protein, high baseline acute physiology and chronic health evaluation II and BAP 65: B=BUN; A=Altered mental status; P=Pulse rate; 65-age years (BAP 65) scores, severe acidosis before NIV treatment and persistent severe acidosis after 1 h of treatment.
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ORIGINAL ARTICLE - INTERSTITIAL LUNG DISEASES Top

Role of fiberoptic bronchoscopy in the diagnosis of pulmonary infiltrates in patients with hematological malignancies p. 340
Yosri Mohamed Kamel Akl, Hamdi Mohamed El Zawam, Reem Ibrahim Mohamed ElKorashy, Mohamed Said Ismail, Amir Kamal Morris Hanna
DOI:10.4103/ejb.ejb_107_17  
Rationale Patients with hematological malignancies are a special challenge to health care providers as they undergo a wide variety of immune-suppressive therapies. Both disease and therapy can cause complications. The lungs may be directly injured through infectious or toxic insults. Early identification of the nature of infiltrates will result in better outcome in the management of these patients. Fiberoptic bronchoscopy (FOB) may be a good tool for indentifying the infiltrate nature by using different diagnostic techniques like transbronchial lung biopsy (TBLB) and bronchoalveolar lavage (BAL). Patients and methods This study was performed over 6 months, in Kasr Al-Aini Hospital, Cairo University. It included 30 patients with hematological malignancies presenting with pulmonary infiltrates confirmed by computed tomography of the chest. All patients underwent history taking, clinical examination, and investigations included complete blood count and coagulation profile, BAL for culture and sensitivity, cytology examination, and TBLB. Results Overall diagnostic yield of FOB was 73.3% in this study. The diagnostic yield of FOB was higher for infectious (43.3%) than both noninfectious (20%) and mixed (10%) etiologies. The combined diagnostic yield of BAL for bacteriological examination and TBLB was higher than that of BAL for cytology examination. Bacteriological examination revealed a predominance for gram-negative bacteria in 62.5% of total culture and sensitivity. Conclusion This study supports the role of FOB as the initial procedure of choice for identifying the nature of pulmonary infiltrates in patients with hematological malignancies. Because our results suggest that BAL and TBLB are complementary, we recommend performing TBLB whenever it is deemed safe. On the contrary, cytological examination of BAL fluids was not helpful in reaching a final diagnosis.
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ORIGINAL ARTICLES - PULMONARY INFECTIONS Top

Fixed-dose combination versus separate drug formula for pulmonary and extrapulmonary tuberculosis p. 346
Maha M El-Kholy, Samiaa H Sadek, Osama Mahran
DOI:10.4103/ejb.ejb_61_17  
Introduction The prescription of an effective and well-tolerated antituberculosis (TB) treatment regimen is an important step in the management of TB. Objective The aim of the present study was comparison between fixed-dose combination (FDC) anti-TB drugs and separate drug formula (SDF) not only in pulmonary tuberculosis (PTB) but also in extrapulmonary tuberculosis (EPTB). Patients and methods A total of 240 patients with TB were included in the present study: 122 patients had PTB and 118 had EPTB. Both patients with PTB and those with EPTB were divided into two groups according to receiving FDC or SDF. All patients had baseline clinical and laboratory data, including blood picture, liver function tests, renal function tests, erythrocyte sedimentation rate, uric acid, and chest radiography. Follow-up clinical, laboratory, and radiology assessments were done during the course of treatment. Patients who received FDC and those who received SDF were compared for clinical, laboratory, radiological improvement, and sputum conversion in PTB during the course of treatment; moreover, they were compared for drug tolerance, compliance with treatment, and development of adverse effects. Results Both FDC and SDF in PTB and EPTB had comparable effect with respect to clinical improvement, and also sputum conversion in PTB; significant change in liver function was observed in PTB among those who received FDC, but better radiological clearance was detected with SDF. Both regimens were comparable with respect to compliance and adverse effects, except for more gastric disturbance with FDC. Conclusion SDF is recommended in patients with borderline liver function, gastrointestinal troubles, and presence of extensive radiological infiltrate.
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Iron-deficiency anemia as a risk factor for acute lower respiratory tract infections in children younger than 5 years p. 352
Ola G Behairy, Osama I Mohammad, Osama S Elshaer
DOI:10.4103/ejb.ejb_67_17  
Background Acute lower respiratory tract infection (ALRTI) is an important cause of morbidity in the developed world and both morbidity and mortality in the developing world. Moreover, iron-deficiency anemia (IDA) is a major health problem in children. Aim The aim was to evaluate IDA as a risk factor for ALRTIs in children. Participants and methods A total of 200 children were enrolled in this study, and they were divided into two groups: group I included 100 children with lower respiratory tract infections and group II included 100 apparently healthy children matched for age and sex as a control group. All enrolled children were subjected to history taking with stress on recurrent chest infection, clinical examination, and chest radiographs. Complete blood counting was done with measures of serum iron, serum ferritin levels, and total iron-binding capacity. Results Anemia was found in 74% of cases and 38% of controls. IDA was present in 60% of cases and 24% of controls. There was a statistically significant increased incidence of anemia [odds ratio (OR) was 4.64] and presence of IDA (OR was 4.75) in group I compared with group II. Regarding recurrent chest infections, there was a statistically significant increased incidence in children with anemia compared with those without anemia (OR was 27.60) and between non-IDA and IDA, as it was significantly higher in children with IDA (OR was 10.26). Conclusion Children with IDA were found to be four times more susceptible to ALRTI and ten times more susceptible to recurrent chest infections when compared with children without anemia.
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CASE REPORTS Top

Diffuse pleural thickening: cases of pseudomesotheliomatous adenocarcinoma and pleural tuberculosis p. 358
Amrith B.P., Animesh Ray, Aanchal Kakkar, Sanjeev Sinha
DOI:10.4103/ejb.ejb_121_17  
Diffuse pleural thickening is a common cause of diagnostic dilemma. We report two cases of pleural thickening that presented with similar clinical and radiological picture, thus clinching a diagnosis hinged on histopathology. In the first case, the histopatholgy and immunohistochemistry was suggestive of adneocarcinoma, thus making the diagnosis of pseudomesotheliomatous adenocarcinoma. In the second case, the histopathology was suggestive of tubercular etiology, which also is a rare presentation of active pleural tuberculosis. These cases highlight the importance of histopathological examination in establishing the etiology in cases of diffuse pleural thickening.
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Reverse Lemierre’s syndrome: a case report p. 363
Ram M Talupula, Animesh Ray, Smita Manchanda, Rita Sood
DOI:10.4103/ejb.ejb_93_17  
We present the case of a 60-year-old diabetic who had acute-onset shortness of breath that was preceded by bilateral thigh and hip pain. He was initially admitted for septic arthritis with community-acquired pneumonia. His respiratory complaints resolved, but he continued to have thigh pain. Ultrasound of the lower limbs showed thrombosis of the deep veins of the thigh and MRI showed a collection in the right thigh suggestive of pyomyositis with thrombosis in deep veins abutting the collection. Contrast enhanced CT (CECT) chest showed multiple peripherally located pneumatoceles and cavities in both the lungs suggestive of septic emboli. Here, we present a case of pyomyositis of thigh muscles causing Deep vein thrombosis (DVT) and septic pulmonary emboli (reverse Lemierre’s syndrome).
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Young man with nonresolving pneumonia p. 367
Nithya Haridas, Asmita Mehta, Tajik S Mohammed, Indu R Nair
DOI:10.4103/ejb.ejb_116_17  
Hamartoma is a benign lung tumor. Parenchymal hamartomas are usually asymptomatic, but endobronchial hamartoma can present with features of obstruction. Here, we present a case of a young man who presented with nonresolving pneumonia. His bronchoscopy showed an endobronchial hamartoma.
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Pericardial cyst masquerading as lung carcinoma p. 370
Viswesvaran Balasubramanian, Shibdas Chakrabarti, Nitesh Gupta, Abhijeet Singh
DOI:10.4103/ejb.ejb_118_17  
Pericardial cyst is a benign congenital malformation, with uncommon incidence of approximately 1 in 100 000. It accounts for 7% of all mediastinal masses and is rarely associated with complications. Prompt discrimination of this benign lesion from metastasis in a patient with malignancy is of paramount significance in deciding exact line of management. Here, we report a case of pericardial cyst masquerading as a metastatic lung carcinoma in a patient previously treated for breast carcinoma.
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