The Main Causes of Bacterial Colonization in Endotracheal Tubes and Tracheal Secretions in Neonates Admitted to the Neonatal Intensive Care Unit.

BACKGROUND: Ventilator-associated pneumonia (VAP) is the second most common nosocomial infection in neonates, admitted to neonatal intensive care units (NICUs). The aim of this study was to identify the main causes of bacterial colonization in endotracheal tubes and tracheal secretions of neonates hospitalized in the NICUs of our university hospitals. MATERIALS AND METHODS: This cross sectional study was conducted during 2015-2016. Thirty-nine neonates, who were under mechanical ventilation in the NICUs of Baqiyatallah and Najmiyeh hospitals of Tehran, Iran, were assessed. The patients were selected using the census sampling method. Gestational age, birth weight, duration of mechanical ventilation, length of hospital stay, tracheal discharge culture, endotracheal tube culture, blood culture, and chest radiography were evaluated. RESULTS: In a total of 39 neonates (50.3% males and 49.7% females) with the mean age of 1.17±1.12 days, bacterial growth was reported in 6 (15.3%) cases. The antibiotic study of tracheal secretion and endotracheal tube cultures showed that 2.6% of patients were resistant to cephalosporins, aminoglycosides, nitrofurantoin, and carbapenem. Moreover, 12.8% were also resistant to fluoroquinolones, besides these antibiotics. CONCLUSION: Tracheal secretion culture is a simple and proper approach for the diagnosis of VAP. Besides reducing the costs, this method can play a significant role in decreasing the incidence of infections.

Associations between anthropometric characteristics and insulin markers in mothers and their neonates and with neonate`s birth weight: An observational cohort study.

Naseh A, Nourbakhsh S, Tohidi M, Sarkhail P, Najafian B, Azizi F. Associations between anthropometric characteristics and insulin markers in mothers and their neonates and with neonate`s birth weight: An observational cohort study. Turk J Pediatr 2017; 59: 625-635. This study aimed to identify possible associations between anthropometric characteristics and insulin markers of mothers and 1) their neonate`s birth weight, and 2) those markers of neonates. A prospective observational cohort of 100 healthy mothers who came to a hospital in Tehran in 2014 from pregnancy to delivery as well as their term neonates comprised the study population. Only newborns with weight within normal range were included. Anthropometric indices and serum glucose and insulin levels were measured in both mothers and neonates. Correlations between maternal body and serum indices and neonate`s serum indices and birth weight were assessed. Maternal weight before pregnancy (r= 0.3, p=0.001), at time of delivery (r= 0.3, p=0.001), and maternal body mass index (BMI) before pregnancy (r= 0.2, p=0.04) positively associated with neonate`s birth weight. For the neonates with normal birth weight, there was no correlation between maternal serum glucose and insulin levels and neonate`s serum glucose and insulin levels or birth weight. Neonate`s serum glucose correlated positively with insulin levels (r= 0.3, p=0.006) and HOMA-IR (r= 0.6, p < 0.0001); and negatively with HOMA-S (r= -0.6, p < 0.0001) and QUICKI (r= -0.5, p < 0.0001). Neonate`s insulin correlated positively with HOMA-IR (r= 0.9, p < 0.0001), and negatively with HOMA-S (r= -0.9, p < 0.0001), QUICKI (r= -0.9, p < 0.0001), gestational age (r= -0.2, p=0.03) and with glucose-insulin (GI) ratio (r= -0.9, p < 0.0001). Neonate`s GI ratio correlated positively with gestational age (r= 0.2, p=0.01). Maternal serum glucose and insulin showed positive correlation (r= 0.4, p < 0.0001). The lowest maternal insulin quartile had dominantly male and the highest quartile had dominantly female neonates (p=0.006). In conclusion, maternal anthropometric measures correlate with neonates` birth weight. Advancing health promotion to normalize these maternal parameters may reduce the incidence of abnormal birth weights among newborns.

Comparison of efficacy and safety of two available natural surfactants in Iran, Curosurf and Survanta in treatment of neonatal respiratory distress syndrome: A randomized clinical trial.

INTRODUCTION: The benefit of surfactant prescription for respiratory distress syndrome (RDS) has been approved. Curosurf and Survanta are two commonly used natural surfactants in Iran. Previous studies did not report priority for one of these two drugs. The present study aimed to compare the effectiveness and safety of Curosurf and Survanta in treatment of RDS. METHODS: In this randomized clinical trial, neonates were born with RDS diagnosis in two governmental and referral hospitals of Tehran (the capital of Iran) in 2014 were randomly selected. Neonates were randomly assigned into two groups receiving 100 mg/kg Curosurf or Survanta as soon as possible after randomization. Complications, mortality and needing the second dose were compared between the two groups. RESULTS: A total 112 patients with the mean gestational age of 32.59 ± 3.39 weeks were evaluated (56 patients in each group). There were no significant differences regarding birth weight, gestational age, delivery method, and parity between the two groups (P > 0.05). The complications were occurred in 18 neonates (32.1%) of Curosurf group and 20 neonates (35.7%) of Survanta group (RR = 0.922, 95% CI = 0.617-1.379). There were no significant differences regarding complications, mortality, and needing nasal CPAP and endotracheal tube between the two groups. In the neonates with gestational age of 29-32 weeks the IVH and NEC incidence were significantly more in Curosurf group compared to Survanta group (27.8% vs 0% and 22.3% vs 0%, P < 0.05). CONCLUSION: There was no significant difference in complications or mortality between those two groups; however Curosurf was associated with less need of ET tube (in >32 birth weeks subgroup) and NCPAP (in 29-32 birth weeks subgroup) (p = 0.008). Further evaluations with longer follow-up duration are needed for comparing these two surfactants.

Efficacy of Tiotropium Bromide and Rehabilitation Treatment on Pulmonary Function of Patients With Sulfur Mustard Lung Injury.

BACKGROUND: Chronic pulmonary complication is the most common delayed toxic effect of sulfur mustard (SM) and it has no treatment so far. OBJECTIVES: To evaluate short-term therapeutic effects of inhaled tiotropium bromide and pulmonary rehabilitation on pulmonary function of patients with SM induced lung injury. PATIENTS AND METHODS: In a randomized clinical trial, using convenient sampling method, 54 patients with chronic lung disease due to SM exposure were recruited in Baqiyatallah General Hospital, Tehran, Iran for a period of 2-month study. They were randomly divided into 3 groups of 18 participants each. Group 1 received routine drugs (Serevent, Flixotide), pulmonary rehabilitation 30 minutes/2 times a week, and tiotropium bromide 18 µg/day. Group 2 was treated with routine drugs and pulmonary rehabilitation and group 3 was only on the routine drugs. cardiopulmonary exercise test (CPET), plethysmographic measurements, and respiratory symptoms evaluation were performed before and after medical intervention. RESULTS: In group 1, compared to group 3, significant differences were found with regard to symptoms of cough ([difference between the first and last visit in group 1: Diff 1] = -1.6, Diff 3 = -0.3, P = 0.01) and nocturnal dyspnea (Diff 1 = -1.9, Diff 3 = 0.0, P = 0.01), likewise, compared to group 2, significant differences were found with regard to lung function parameters of forced vital capacity (Diff 1 = 3.0, Diff 2 = -3.5, P = 0.03), forced expiratory volume in one second (Diff 1 = 3.9, Diff 2 = -5.6, P = 0.009), maximal mid-expiratory flow rate 25% - 75% (Diff 1 = 1.5, Diff 2 = -3.2, P = 0.007) and peak expiratory flow (Diff 1 = -2.06, Diff 2 = -4.3, P = 0.04). Total lung capacity (Diff 2 = 9.28, Diff 3 = -12.07, P = 0.02) and residual volume (Diff2 = 32.1, Diff3 = -27.6, P = 0.04) were increased in group 2 compared to group 3. There were no significant differences with regard to CPET results among all groups (P > 0.05). CONCLUSIONS: Inhalation of tiotropium bromide in combination with pulmonary rehabilitation could improve some plethysmographic lung volumes and clinical outcomes in patients with chronic pulmonary disease due to SM. Short-term prescription of pulmonary rehabilitation has no effect on CPET of patients.

Serum level of substance P in patients with lung injuries due to sulfur mustard.

BACKGROUND: Chronic bronchiolitis is the most important problems of chemical victims of mustard gas. Diverse studies suggest that substance P (SP) as a member of tachykinin neuropeptides, has a significant role in the neurogenic inflammation processes of the airways and lungs. We aimed to determine the serum level of SP in chemical victims of mustard gas and compare it with normal subjects. MATERIALS AND METHODS: The chemical victims were divided into the 2 groups of 30:A group with mild to moderate pulmonary symptoms and other group with moderate to severe symptoms and compared with 3(rd) group as healthy controls. After preparing our samples and using the SP kit, final analysis was performed with enzyme-linked immunosorbent assay reader. RESULTS: The Concentration of circulatory SP levels in the chemical patients was 2.86 ± 1.47 ng/ml and had not a significant difference with the control group (3.15 ± 1.03 ng/ml) (P > 0.05). The circulatory SP levels were 2.48 ± 0.92 ng/ml and 3.28 ± 1.73 ng/ml in patients with moderate to severe symptoms and mild to moderates (P < 0.05) respectively. CONCLUSION: The SP may have a role in pulmonary complications of mustard gas. The lower level of SP in the moderate to severe patients may be due to corticosteroid consumption in such severe cases. However, further studies are needed to clarify the roles and mechanism of SP in this setting.

The role of serum level of interleukin-6 in severity of pulmonary complications of sulfur mustard injuries.

Diverse studies suggest that interleukin-6 (IL6), as a member of cytokines family, has a major role in inflammatory processes of airways and lungs. In this study, an attempt was made to determine the serum level of IL6 in sulfur mustard (SM) injured patients and its comparison with controls. The measured IL6 mean level in patients with chemical injuries (0.76±0.3 ng/ml) was significantly higher than the control group's mean level (0.34±0.12 ng/ml). Furthermore, patients with moderate to severe symptoms had a serum level of (0.95±0.92 ng/ml) which was significantly higher than mild (0.47±0.54) and control (0.34±0.12) groups. The outcome of this research program demonstrates that an increase in serum level of IL6 can have a role in pulmonary complications of SM, similar to other well defined pulmonary diseases.  However, further studies are required to clarify the role and mechanism of IL6 in such patients.

Intramuscular compared to intravenous midazolam for paediatric sedation: A study on cardiopulmonary safety and effectiveness.

BACKGROUND: Sedation in children remains a controversial issue in emergency departments (ED). Midazolam, as a benzodiazepine is widely used for procedural sedation among paediatrics. We compared the effectiveness and safety of two forms of midazolam prescription; intramuscular (IM) and intravenous (IV). PATIENTS AND METHODS: A cohort study was conducted on two matched groups of 30 children referred to our ED between 2010 and 2011. The first group received IM midazolam (0.3 mg/kg) and the second group received IV midazolam (0.15 mg/kg) for sedation. For evaluating effectiveness, sedation, irritation and cooperation score were followed every 15 min for 60 min and for safety assessment, vital signs and O 2 saturation were observed. RESULTS: Mean age was 6.18 ± 2.88 years and 31 patients (51.7%) were male. All patients were sedated completely after using first dose. There was an overall complication rate of 68.3%. 35 (58.3%) patients presented euphoria as the most common complication, but there was no statistical difference between the two groups (P = 0.396). Cases who received IV midazolam became sedated faster than those received IM midazolam (P > 0.001). The vital signs including heart rate, respiratory rate, systolic blood pressure and O 2 saturation changed significantly between and within groups during the sedation (P < 0.05). CONCLUSION: Both forms of midazolam, IM and IV, are effective and safe for paediatric sedation in ED. Although the sedative with IV form might appear sooner, IM form of midazolam can be effectively used in patient with limited IV access. Patients are better to observe closely for psychological side-effects.

Early surfactant therapy with nasal continuous positive airway pressure or continued mechanical ventilation in very low birth weight neonates with respiratory distress syndrome.

BACKGROUND: Various strategies have been suggested for the treatment of respiratory distress syndrome (RDS). OBJECTIVES: The aim of this study was to compare the efficacies of two common methods of RDS management among neonates with low birth weight. PATIENTS AND METHODS: A cohort study was conducted on 98 neonates with definite diagnosis of RDS during 2008-2009. The neonates were divided into two groups by a blinded supervisor using simple randomization (odd and even numbers). Forty-five cases in the first group were treated with intubation, surfactant therapy, extubation (INSURE method) followed by nasal continuous positive airway pressure (N.CPAP) and 53 cases in the second group underwent intubation, surfactant therapy followed by mechanical ventilation (MV). RESULTS: Five (11.1%) cases in the first group and 23 (43%) cases in the second group expired during the study. The rates of MV dependency among cases with INSURE failure and cases in the MV group were 37% and 83%, respectively (P < 0.001). Birth weight (BW) (P = 0.017), presence of retinopathy of prematurity (P = 0.022), C/S delivery (P = 0.029) and presence of lung bleeding (P = 0.010) could significantly predict mortality in the second group, although only BW (P = 0.029) had a significant impact on the mortality rate in the first group. Moreover, BW was significantly related to the success rate in the first group (P = 0.001). CONCLUSIONS: Our findings demonstrated that INSURE plus NCPAP was more effective than the routine method (permanent intubation after surfactant prescription). In addition, the lower rates of mortality, MV dependency, duration of hospitalization, and complications were observed in cases treated with the INSURE method compared to the routine one.

Serum matrix metalloproteinase levels in patients exposed to sulfur mustard.

BACKGROUND: Matrix metalloproteinases (MMPs) are a group of endopeptidases which comprised of various types. These proteolytic enzymes are zinc-dependent and play role in degradation of extracellular matrix (ECM). Various types of cells such as macrophages, fibroblasts, neutrophils, synovial cells and some epithelial cells secrete MMPs. According to previous studies on bronchiolitis and respiratory tract lesions in these patients and unknown pathophysiology mechanism up to date, this cross-sectional study was performed. OBJECTIVES: The aim of this study was to compare the serum MMP level in patients with chemical injuries and normal people and also determine the role of these parameters in pulmonary disorders . MATERIALS AND METHODS: In this cross-sectional study, 25 Iranian patients exposed to the sulfur mustard and 25 unexposed participants as the control group were enrolled. Serum samples were collected from two groups and stored at -70˚C until the measurement of MMPs and TIMPs. ELISA kit was used for measurement of MMP and TIMP based on the kit's instruction. For validations in measurement, all samples were analyzed duplicate and in some cases triplicate. RESULTS: The mean level of MMP-9 in serum of chemically-injured group was 1592.42 and this amount in normal group was 679.72 .So there was a significant difference between two groups (P = 0.001) and the mean level of MMP-8 in serum of patients group was 49.10 and in normal group was 35.53. Then there was no significant difference between two groups (P = 0.197). The mean levels of MMP-1 and MMP-2 was not significantly different (P value > 0.05) in the patient and normal groups. And also the mean levels of TIMP-1 and TIMP-2 was not significantly different (P > 0.05) in the patients and normal groups. CONCLUSIONS: In summary, serum MMPs in chemically-injured has shown no significant difference with normal people except for the MMP-9.

Evaluation of Aggregometery Parameters and Efficacy of Plavix versus Clopidex in Patients Suffering from Ischemic Heart Disease: A Randomized Double Blind Clinical Trial.

BACKGROUND: Ischemic heart disease is the leading cause of death in most societies. In a pathophysiologic point of view, it chiefly results from the formation of thrombus in coronary arteries which could not be only prevented by aspirin. Many of clinical trials have shown the long-term benefits of antiplatelet drugs in reducing the risk of thrombotic accidents. OBJECTIVES: Clopidogrel is a thienopyridine derivative used to prevent platelets from adhering together by direct inhibition of Adenosine diphosphate (ADP), the major factor behind platelets aggregation. Sanofi-Aventis and Bristol-Myers are companies that produce Clopidogrel by the name of Clopidogrel bisulfate. Its trade name is Plavix, nonetheless in Iran it is distributed under the name of Clopidex by Exir Company. In this study we are to compare Plavix and Clopidex in terms of efficacy as well as aggregometry parameters like ADP and PRP (Platelet Rich Plasma). PATIENTS AND METHODS: This is a double blind clinical trial in which we had two groups of patients suffering from Ischemic heart disease who were selected by inclusion criteria. Group A (36 patients) took Plavix (75 mg/d) and group B (36 patients) used clopidex (75 mg/d) both for 30 days. The aggregometry parameters also consisted of PRP and ADP that were run on the patients before and after the study. Finally, a comparison of aforementioned tests, quality of life, lab parameters and compliance in both groups was provided. RESULTS: In groups A and B, the mean levels of PRP before the study were 348000 and 340000/µL respectively. The ADPs were also 73/76 and 68/07 µM that showed no significant difference (P > 0.05).The Means of ADP5 in group A before and after the study were 66.40 and 43.84 µM respectively that there was significant difference (P = 0.001). The Means of ADP5 in group B before and after the study were 58.04 and 40.16 µM respectively that there was significant difference (P < 0.001).The Means of ADP20 in group A before and after the study were 73.76 and 54.97 µM respectively which showed significant difference (P < 0.001). The Means of ADP20 in group B before and after the study were 68.07 and 52.49 µM respectively which showed significant difference (P = 0.001). Difference of ADP5 between group A and B was not significant (P = 0.495). Difference of ADP20 between group A and B was not significant (P = 0.721). The Means of PRP in group A before and after the study were 348000 and 335000/ µL respectively that there was no significant difference (P = 0.66). The Means of PRP in group B before and after the study were 340000 and 336000/ µL respectively that indicated no significant difference (P = 0.81). Difference of PRP between group A and B was not significant (P = 0.563). CONCLUSIONS: Our findings suggested that both drugs significantly lessen the ADP level; even so there was no significant difference between two groups in PRP and ADP factors.

Systemic complications of trinitrotoluene (TNT) in exposed workers.

INTRODUCTION: 2,4,6-trinitrotoluene (TNT) has been widely used as an explosive. TNT can induce some well-recognized toxic impacts comprising toxic hepatitis, aplastic anemia and cataract. The aim of study was evaluation of TNT exposed workers for systemic complication. METHODS: In a cross-sectional study, we carried out Liver Function Test (LFT), complete blood count (CBC) and slit lamp biomicroscopy to compare the prevalence and severity of these 3 complications between 47 male TNT exposed workers (with at least one year continuous experience of TNT exposure) and 43 unexposed male hospital worker who hadn't had any previous contacts with TNT. We also performed Pulmonary Function Test (PFT) to assess the probable obstructive/restrictive abnormalities, caused by TNT. RESULTS: Mean alkaline phosphatase (ALP) level of TNT exposed group was significantly higher than the unexposed group (p = 0.023) Forced Expiratory Volume in one second to Forced Vital Capacity (FEV1/FVC) ratios of both groups were in the range of restrictive pattern (82.03% and 81.42% for the exposed and unexposed group, respectively) with no meaningful difference. We didn't find out any specific TNT induced cataract and general cortical cataract (CC) and nuclear sclerotic cataract (NSC) prevalence was not significantly different. DISCUSSION: we haven't found TNT as a chemical, causing toxic hepatitis or aplastic anemia; neither did we find it as a compound, responsible for a meaningful increase in cataract prevalence. However, due to the increased ALP serum levels and FEV1/FVC ratios among TNT workers, safety precautions are advised.