The role of N-acetylcysteine in the management of acute and chronic pulmonary complications of sulfur mustard: a literature review.

CONTEXT: Sulfur mustard exposure, as the most widely used chemical weapon, can lead to acute and long-term pulmonary complications via various pathways, such as triggering an imbalance between the oxidant and antioxidant system. Currently, there is no validated antidote, chemoprophylaxis and curative modality for pulmonary toxicities secondary to sulfur mustard exposure. OBJECTIVE: The aim of this literature review is to collect available experimental and clinical data on the efficacy of N-acetylcysteine (NAC), as a prominent antioxidant agent, in the prevention and/or treatment of sulfur mustard-induced acute and chronic pulmonary toxicities. METHODS: A literature search was performed by the relevant keywords like "N-acetyl cysteine", "Sulfur mustard" and "Lung injury" in databases such as Scopus, Medline, Embase and ISI Web of Knowledge. No time limitation was considered. Nineteen articles were selected for review. RESULTS: A number of in vitro and experimental studies concluded that oral, intravenous, intraperitoneal and intra-tracheal administration of NAC is effective in the management of sulfur mustard-induced acute lung injury, in a time-dependent manner, via direct scavenging, inhibition of oxidative stress, inflammatory responses and apoptosis. In addition, oral NAC alone (1200 or 1800 mg/day for 4 months) or at a dose 600 mg/day for 6 months in combination with clarithromycin (500 mg/day) have led to improvements of clinical and paraclinical pulmonary parameters of patients with bronchiolitis obliterans due to sulfur mustard, through undetermined mechanisms. CONCLUSION: Despite limitations of relevant experimental and clinical studies, NAC can be considered as a candidate agent for prevention and/or treatment of sulfur mustard-induced acute lung injuries, as well as its long-term pulmonary toxicities, especially bronchiolitis obliterans.

Curcuminoid treatment for knee osteoarthritis: a randomized double-blind placebo-controlled trial.

Treatment of osteoarthritis (OA) is challenging owing to the inefficacy and long-term adverse events of currently available medications including non-steroidal anti-inflammatory drugs. Curcuminoids are polyphenolic phytochemicals with established anti-inflammatory properties and protective effects on chondrocytes. The aim of this study is to investigate the clinical efficacy of curcuminoids in patients suffering from knee OA. A pilot randomized double-blind placebo-control parallel-group clinical trial was conducted among patients with mild-to-moderate knee OA. Patients were assigned to curcuminoids (1500 mg/day in 3 divided doses; n = 19) or matched placebo (n = 21) for 6 weeks. Efficacy measures were changes in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analogue scale (VAS) and Lequesne's pain functional index (LPFI) scores during the study. There was no significant difference in age, gender, body mass index, and VAS, WOMAC and LPFI scores between the study groups at baseline (p > 0.05). Treatment with curcuminoids was associated with significantly greater reductions in WOMAC (p = 0.001), VAS (p < 0.001) and LPFI (p = 0.013) scores compared with placebo. With respect to WOMAC subscales, there were significant improvements in the pain and physical function scores (p < 0.001) but not stiffness score (p > 0.05). There was no considerable adverse effect in both groups. To conclude, curcuminoids represent an effective and safe alternative treatment for OA.

Comparison between traction-countertraction and modified scapular manipulation for reduction of shoulder dislocation.

OBJECTIVE: One of the most common joint dislocations presented to the emergency department (ED) is anterior shoulder dislocation (ASD). Various techniques for the treatment of this abnormality have been suggested. In this study, we evaluated the efficacy and success rate of modified scapular manipulation (MSM) as a painless procedure compared to traction-countertraction (TCT) for reduction of ASD. METHODS: Patients with ASD who were presented to ED of Baqiyatallah Hospital, Tehran during 2011 were included. They were randomly divided into MSM group or TCT group and then pain at reduction, time of reduction, duration of hospitalization, and success rate were compared. In TCT group, reduction was performed using sedative and antipain medications. RESULTS: Ninety seven patients (81.6% male) with a mean age of 34.15 years±13.48 years were studied. The reduction time between both groups showed a significant difference (470.88 seconds±227.59 seconds for TCT group, 79.35 seconds±82.49 seconds for MSM group, P<0.001). The success rate in MSM group in the first and second effort were 89% and 97% whereas 73% and 100% in the TCT group respectively (P<0.001). CONCLUSION: It seems that the manipulation technique can be more successful than the TCT method at the first effort whilst the second effort has the opposite results. Also MSM can be safer, cheaper and more acceptable for patients than TCT as a standard traditional method.

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.

Efficacy of omeprazole on cough, pulmonary function and quality of life of patients with sulfur mustard lung injury: A placebo-control, cross-over clinical trial study.

BACKGROUND: Gastro-esophageal reflux disease (GERD) is prevalent and related to more severe disease in patients with respiratory problems. We evaluated the effects of antireflux therapy in warfare victims of exposure to Mustard gas with chronic cough. MATERIALS AND METHODS: This randomized, double-blind, placebo-controlled, cross-over study was conducted on 45 cases of sulfur mustard injury with chronic cough (≥8 weeks) and GERD. Patients were randomized into two groups, receiving either 20 mg twice daily omeprazole-placebo (OP) or matching placebo (placebo-omeprazole [PO]) for 4 months, followed by a 1-month washout period and the alternative treatment for 4 months. Assessments included GERD and cough, quality of life, and pulmonary function using spirometry. Leicester Cough Questionnaire and SF-36 were used for measuring quality of life. RESULTS: Patients in the OP group experienced a more decrease than those in the PO group in severity of Leicester cough scores during the first 4-month of trial. After crossing the groups, the OP group experienced an increase (P = 0.036) and the PO group experienced a nonsignificant decrease (P = 0.104) in the severity of scores. The OP group also experienced improvement in GERD symptoms and quality of life at the end of the trial, but changes in the PO group was not significant. There was no significant change in respiratory function indices in any groups. CONCLUSION: Long-term treatment with high-dose omeprazole improved GERD as well as cough, and quality of life, but not changed respiratory function indices in sulfur mustard injured cases with respiratory symptoms.

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.

Is it necessary to treat mild asthmatic patients with the full dose treatment?

BACKGROUND: Routine protocol of asthma treatment has been focused on symptom suppression but severity of inflammation and spirometry findings may be neglected. We investigated the efficacy of full dose treatment protocol on patients with mild asthma symptoms with normal spirometry. MATERIALS AND METHODS: A before-after clinical trial study was conducted on patients with asthma symptoms (dyspnea, cough, and wheezing), while they had a near to normal pulmonary function test. Full dose treatment protocol (prednisolone 1 mg/kg for 5 days then fluticasone spray 250 mg four puffs daily plus salmeterol spray 25 mg four puffs daily), which was routinely used for severe asthma, was administrated and patients were followed up for 2 months. RESULTS: Sixty-eight patients (mean age (±SD) = 43.77 ± 10.70 years, female/male ratio; 47/53%) finally finished the study. At the baseline, mean forced expiratory volume in first second (FEV1) and forced vital capacity (FVC) were 91 ± 12% and 87 ± 11% of the predicted value, respectively. Two months after treatment, the mean FEV1 and FVC were 105 ± 14% and 97 ± 10%, respectively, which both improved compared with the baseline, significantly (P < 0.001). Frequencies of cough and dyspnea were significantly decreased (P = 0.041 and 0.034, respectively). CONCLUSION: Our result declared that full dose treatment can improve spirometry amounts and frequency of symptoms in patients with near to normal spirometry and obvious asthmatic symptoms. Routine treatment protocol of mild asthma recommends sole short-acting b2 receptor agonist, but it seems that pulmonary function and volume can be increased with more aggressive treatment.

Prevalence, molecular characteristics and risk factors for cryptosporidiosis among Iranian immunocompromised patients.

Cryptosporidium spp. is a major cause of diarrhea in developing countries, mainly affecting people with compromised immune systems in general and HIV-infected individuals with low CD4 + T-cell counts in particular. This infection is self-limiting in healthy persons; however, it can be severe, progressive and persistent in those who are immunocompromised. There are few published studies concerning cryptosporidiosis and Cryptosporidium genotypes in Iranian immunocompromised patients and none of them describe risk factors. This study was undertaken to identify prevalence, genotypes and risk factors for cryptosporidiosis in immunocompromised patients. Three fecal samples were obtained at two day intervals from each of the 183 patients and processed with modified Ziehl-Neelsen staining methods and 18S rRNA gene amplification and sequencing. The overall infection prevalence was 6%. Cryptosporidium parvum was identified in isolates from five HIV-infected patients, one patient who had undergone bone marrow transplantation and one with chronic lymphocytic leukemia. Cryptosporidium hominis was identified in isolates from two HIV-infected patients and two patients with acute lymphocytic leukemia. According to univariate analysis, the statistically significant factors were diarrhea (OR = 21.7, CI = 2.83-78.4, P= 0.003), CD4 + lymphocytes less than 100 cells/mm(3) (OR = 41.3, CI = 13.45-114.8, P < 0.0001), other microbial infections (OR = 7.1321.7, CI = 1.97-25.73, P = 0.006), weight loss (OR = 73.78, CI = 15.5-350, P < 0.0001), abdominal pain (OR = 10.29, CI = 2.81-37.74.4, P= 0.001), dehydration (OR = 72.1, CI = 17.6-341.5, P < 0.0001), vomiting (OR = 4.87, CI = 1.4-16.9, P= 0.015), nausea (OR = 9.4, CI = 2.38-37.2, P < 0.001), highly active antiretroviral therapy (OR = 0.089, CI = 0.01-0.8, P= 0.015) and diarrhea in household members (OR = 7.37, CI = 2.04-26.66, P= 0.001). After multivariate analysis and a backward deletion process, only < 100 CD4 + T-lymphocytes/mm(3) maintained a significant association with infection. The authors recommend that this infection should be suspected in patients with diarrhea, weight loss and dehydration in general and in diarrheal individuals with < 100 CD4 + T-lymphocytes/mm(3).

Clinical and paraclinical guidelines for management of sulfur mustard induced bronchiolitis obliterans; from bench to bedside.

It is well documented that inhalation of sulfur mustard (SM) causes injury to the respiratory system. Many Iranian civilians and war veterans are suffering from late respiratory complications of SM exposure. Recent studies have shown that bronchiolitis obliterans (BO) is the major cause of respiratory complications following SM exposure. In this review, we focus on the clinical, pulmonary, radiological, immunological and pathological manifestations in SM-induced BO with intent to provide a practical, clinical and paraclinical guideline for diagnosis and step-wise workup of these patients, which may be used to manage similar lung injuries induced by other similar inhaled toxins.

Cochlear implantation outcomes in children with Waardenburg syndrome.

Waardenburg syndrome (WS) is an autosomal dominant disease, characterized by dystopia canthorum, hyperplasia of the eyebrows, heterochromia iridis, white forelock, and congenital sensori-neural hearing loss (SNHL). The aim of this study was to evaluate the outcome of cochlear implantation in children with WS and compare it with children with pure SNHL. In a prospective study we evaluated 336 cochlear implanted children from 2008 to 2010. The WS was diagnosed by its established criteria and for control group children without any dysmorphic features, anatomical, behavioral, and developmental disorders were also enrolled. We evaluated children of both groups 1 year after cochlear implantation by categories of auditory performance (CAP) and speech intelligibility rating (SIR) tests. Eighty-one children out of the total 336 who had SNHL were included in study. Out of these 75 (22.3%) were healthy and six (1.78%) had WS. Of the 75 healthy children 40 (53.3%) were girls, while of the six children with WS, three (50%) were girls. There was a significant difference in SIR between WS and cases with pure SNHL (2.67 ± 1.03 vs. 3.79 ± 1.11, p = 021) however, the difference was not significant in CAP (4 ± 1.26 vs. 5.13 ± 1.13, p = 0.082). Prevalence of WS was 1.78% at Baqiyatallah Cochlear Implant Center. One year after implantation there was no significant difference in auditory outcome; however, the difference in speech outcome was significant between WS and cases with pure SNHL.

COVID-19 in rheumatoid arthritis cases: an Iranian referral center experience.

Coronavirus infections, known as COVID-19, can induce a fatal respiratory system infection and also affect other organs, such as the kidney and heart. The mortality rate has been estimated between 1 and 5% in previous reports; however, the mortality and morbidity can be higher in patients with the immune-deficiency condition. Rheumatoid arthritis (RA) is one of the most rheumatoid disorders, and it is important to report their clinical and paraclinical data when affected with COVID-19. Evidence about their laboratory and radiologic findings is limited. In this case series, 10 cases of chronic and approved rheumatoid arthritis (RA) affected by COVID-19 are presented. Only 40% had dry cough, but myalgia and weakness as the general first presentation of infections was reported in most cases (80%). Gastrointestinal symptoms, including nausea/vomiting, diarrhea, anorexia, and abdominal pain, were reported in 50% of individuals. In blood cell count, 30% of cases had thrombocytopenia, and ESR in all cases was positive. Abnormal CRP and elevated LDH were seen in 90% of cases. In HRCT assessment, all cases had an abnormal parenchymal pattern, and 90% of cases presented the usual pattern of COVID-19 (bilateral multifocal GGO/consolidation). Although it is a limited report, these findings are helpful for comparison of clinical and paraclinical cases in RA cases with normal cases.

"Pulmonary target sign" as a diagnostic feature in chest computed tomography of COVID-19.

BACKGROUND: In chest computed tomography (CT) scan, bilateral peripheral multifocal ground-glass opacities, linear opacities, reversed halo sign, and crazy-paving pattern are suggestive for coronavirus disease 2019 (COVID-19) in clinically suspicious cases, but they are not specific for the diagnosis, as other viral pneumonias, like influenza and some viral pneumonia may show similar imaging findings. AIM: To find a specific imaging feature of the disease would be a welcome guide in diagnosis and management of challenging cases. METHODS: Chest CT imaging findings of 650 patients admitted to a university Hospital in Tehran, Iran between January 2020 and July 2020 with confirmed COVID-19 infection by RT-PCR were reviewed by two expert radiologists. In addition to common non-specific imaging findings of COVID-19 pneumonia, radiologic characteristics of "pulmonary target sign" (PTS) were assessed. PTS is defined as a circular appearance of non-involved pulmonary parenchyma, which encompass a central hyperdense dot surrounded by ground-glass or alveolar opacities. RESULTS: PTS were presented in 32 cases (frequency 4.9%). The location of the lesions in 31 of the 32 cases (96.8%) was peripheral, while 4 of the 31 cases had lesions both peripherally and centrally. In 25 cases, the lesions were located near the pleural surface and considered pleural based and half of the lesions (at least one lesion) were in the lower segments and lobes of the lungs. 22 cases had multiple lesions with a > 68% frequency. More than 87% of cases had an adjacent bronchovascular bundle. Ground-glass opacities were detectable adjacent or close to the lesions in 30 cases (93%) and only in 7 cases (21%) was consolidation adjacent to the lesions. CONCLUSION: Although it is not frequent in COVID-19, familiarity with this feature may help radiologists and physicians distinguish the disease from other viral and non-infectious pneumonias in challenging cases.

Convalescent plasma therapy in a pregnant COVID-19 patient with a dramatic clinical and imaging response: A case report.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a novel very contagious infection which was designated a pandemic in all countries of the world in April 2020. Its presentation varies from mild to severe infection, but the majority of infected patients have mild manifestations. Many therapeutic choices have been suggested to treat the infection, but none are fully effective. CASE SUMMARY: Herein we present a 26-year-old woman with a twin pregnancy at 36 wk and one day gestation with confirmed COVID-19 who responded dramatically to convalescent plasma therapy (CPT) and Favipiravir. CONCLUSION: Although this case report shows the efficacy of CPT in addition to usual medications used for COVID-19, there are many questions that need to be answered regarding dosage, para-clinical efficacy, side effects and combination therapy.

From Radiological Manifestations to Pulmonary Pathogenesis of COVID-19: A Bench to Bedside Review.

In this review, we aim to assess previous radiologic studies in COVID-19 and suggest a pulmonary pathogenesis based on radiologic findings. Although radiologic features are not specific and there is heterogeneity in symptoms and radiologic and clinical manifestation, we suggest that the dominant pattern of computed tomography is consistent with limited pneumonia, followed by interstitial pneumonitis and organizing pneumonia.

Primary duodenal malignant melanoma: A case report.

BACKGROUND: Melanoma is a neoplasm derived commonly from melanocytic cells of skin. Although coetaneous presentation of malignant melanoma is easily recognizable, the presentation of melanoma in other organs is so confusing. In particular, when it metastasizes to other organs, many bizarre figures and unusual organs may be involved. In this report, we present a case of primary duodenal malignant melanoma. CASE PRESENTATION: A 68-year-old man presented with a history of iron deficiency anemia. The upper gastrointestinal endoscopy showed a prominent papilla of duodenum along with an ulcerative lesion adjacent to second part of duodenum. Histopathologic evaluation showed a high-grade malignant neoplasm involving the bowel wall which was labeled for S100 protein and markers of melanocytic differentiation; Melan-A indicating the definitive diagnosis of malignant melanoma of the second portion of duodenal mucosa. CONCLUSIONS: In patients with a history of iron deficiency anemia, any GI symptom should be evaluated carefully. However, the diagnosis of primary GI melanomas in patients without any history of melanoma is possible. Full medical investigations are recommended in these patients with primary mucosal lesions.