The allograft injury marker CXCL9 determines prognosis of anti-HLA antibodies after lung transplantation.

Despite the common detection of non-donor specific anti-HLA antibodies (non-DSAs) after lung transplantation, their clinical significance remains unclear. In this retrospective single-center cohort study of 325 lung transplant recipients, we evaluated the association between donor-specific HLA antibodies (DSAs) and non-DSAs with subsequent CLAD development. DSAs were detected in 30% of recipients and were associated with increased CLAD risk, with higher HRs for both de novo and high MFI (>5000) DSAs. Non-DSAs were detected in 56% of recipients, and 85% of DSA positive tests had concurrent non-DSAs. In general, non-DSAs did not increase CLAD risk in multivariable models accounting for DSAs. However, non-DSAs in conjunction with high BAL CXCL9 levels were associated with increased CLAD risk. Multivariable proportional hazards models demonstrate the importance of the HLA antibody-CXCL9 interaction: CLAD risk increases when HLA antibodies (both DSAs and non-DSAs) are detected in conjunction with high CXCL9. Conversely, CLAD risk is not increased when HLA antibodies are detected with low CXCL9. This study supports the potential utility of BAL CXCL9 measurement as a biomarker to risk stratify HLA antibodies for future CLAD. The ability to discriminate between high versus low-risk HLA antibodies may improve management by allowing for guided treatment decisions.

The effects of atorvastatin on mustard-gas-exposed patients with chronic obstructive pulmonary disease: A randomized controlled trial.

BACKGROUND: Statins have anti-inflammatory effects in patients with chronic obstructive pulmonary disease (COPD). This study designed to evaluate the effects of atorvastatin on serum highly sensitive C-reactive protein (hs-CRP) and pulmonary function in sulfur mustard exposed patients with COPD. MATERIALS AND METHODS: Fifty patients with chronic obstructive pulmonary disease due to sulfur mustard and high serum hs-CRP entered in this study. Participants were randomized to receive 40 mg atorvastatin or placebo in a double-blind clinical trial. Forty-five patients completed the study (n = 23 atorvastatin and n = 22 placebo). Pulse oximetry (SpO2), pulmonary function test (PFT), and 6 min walk distance test (6MWD) was measured. COPD assessment test (CAT) and St. George's respiratory questionnaire (SGRQ) were also completed by patients at the beginning of trial and after 9 weeks of prescription of 40 mg/day atorvastatin or placebo. At fourth week, SpO2, PFT, and 6MWD were again measured. After 9 weeks serum hs-CRP was re-measured. RESULTS: There was no significant difference between atorvastatin and the placebo group in SpO2, FEV1, and 6MWD after fourth week (P = 0.79, P = 0.12, P = 0.12, respectively). The difference between baseline and ninth week was calculated for two groups of trial and control in term of serum hs-CRP, SpO2, FEV1, and 6MWD. Significant improvement was not observed between two groups in above mentioned variables (P = 0.35, P = 0.28, P = 0.94, P = 0.43, respectively). However, the quality of life was improved by administration of atorvastatin using the CAT score (P < 0.001) and SGRQ total score (P = 0.004). CONCLUSION: Atorvastatin does not alter serum hs-CRP and lung functions but may improve quality of life in SM-injured patients with COPD.

Sentinel ode apping in on-small ell ung ancer sing an ntraoperative adiotracer echnique.

OBJECTIVES: Lymph node metastases are the most significant prognostic factor in localized non-small cell lung cancer (NSCLC). Identification of the first nodal drainage site (sentinel node) may improve detection of metastatic nodes. Extended surgeries, such as lobectomy or pneumonectomy with lymph node dissection, are among the therapeutic options of higher acceptability. Sentinel node biopsy can be an alternative approach to less invasive surgeries. The current study was conducted to evaluate the accuracy of sentinel node mapping in patients with NSCLC using an intraoperative radiotracer techniques. METHODS: This prospective study was conducted on 21 patients with biopsy-proven NSCLC who were candidates for sentinel node mapping during 2012-2014. All patients underwent thoracoabdominal computed tomography, based on which they had no lymph node involvement. Immediately after thoracotomy and before mobilizing the tumor, peritumoral injection of 2mCi/0.4 mL Tc-99m- phytate was performed in 4 corners of tumor. After mobilization of the tumoral tissues, the sentinel nodes were searched for in the hillar and mediastinal areas using hand-held gamma probe . Any lymph node with in vivo count twice the background was considered as sentinel node and removed and sent for frozen section evaluation. All dissected nodes were evaluated by step sectioning and hematoxylin and eosin staining (H&E).The recorded data included age, gender, kind of pathology, site of lesion, number of dissected sentinel nodes, number of sentinel nodes, and site of sentinel nodes. Data analysis was performed in SPSS software (version 22). RESULTS: The mean age of the patients was 58.52±11.46 years with a male to female ratio of 15/6. The left lower lobe was the most commonly affected site (30.09%). Squamous cell carcinoma and adenocarcinoma were detected in 11 and 10 subjects, respectively. A total of 120 lymph nodes were harvested with the mean number of 5.71±2.9 lymph nodes per patient. At least one sentinel node was identified in each patient, resulting in a detection rate of 95.2%. The mean number of sentinel nodes per patient was 3.61±2. Frozen section results showed 100% concordance with the results of hematoxylin and eosin staining. CONCLUSION: Based on the findings, sentinel node mapping can be considered feasible and accurate for lymph node staging and NSCLC treatment.

The pulmonary artery-aorta ratio: Is it related to quality of life in chronic obstructive pulmonary disease?

INTRODUCTION: Little is known about the relationship between health status and pulmonary artery diameter in chronic obstructive pulmonary disease (COPD) patients. The aim of this study was to evaluate correlation between pulmonary artery-aorta ratio (P-A ratio) and health status of the individuals, using COPD assessment test (CAT). MATERIALS AND METHODS: In a cross-sectional study, 112 COPD patients were recruited. The severity of COPD was determined by global initiative for obstructive lung disease (GOLD). After digital chest CT scan, the P-A ratio was measured at the level of bifurcation and compared with CAT score, GOLD stage, exacerbation rate and Modified Medical Research Council (MMRC) score. RESULTS: The average P-A ratio was 0.89 ± 0.16 and 62.5% of patients had ratio less than one. The P-A ratio correlates significantly with different GOLD stages, CAT score and MMRC score (P < .001, P < .001, P < .001, respectively). Compared patients with low P-A ratio (<1), those with high P-A ratio (≥ 1) showed higher CAT score [11.94 ± 5.94 vs 25.17 ± 5.84] (P < .001). The P-A ratio was significantly higher in frequent (≥2) comparing low (<2) exacerbations [1.07 ± 0.07 vs 0.77 ± 0.06] (P < .001). CONCLUSION: Significant correlations were found between P-A ratio and GOLD, exacerbation rate and health status, using CAT of patients with COPD. These findings also may suggest the potential role of P-A ratio, in the management of COPD patients.

The effect of fresh frozen plasma in severe closed head injury.

OBJECTIVE: Traumatic brain injury (TBI) is one of the most common causes of morbidity and mortality. Coagulopathy, commonly occurring after severe TBI, is associated with poor outcome and secondary complications, especially delayed traumatic intracerebral hematoma (DTICH). In this study we evaluated the effect of fresh frozen plasma (FFP) on the reduction in the incidence of DTICH in severe closed head injury victims. METHODS: This study was carried out as a double-blind randomized clinical trial. Ninety patients were entered in two parallel groups taking either FFP or normal saline (N/S). Patients' selection criteria for both groups were: severe closed head injury (Glasgow coma scale < or =8), no mass lesion required evacuation and no history of coagulopathy. The clinical findings, laboratory data, computed tomography (CT) scans and Glasgow outcome scale after 1 month were assessed and compared in two groups. RESULTS: Out of 90 patients, 44 received FFP and 46 received N/S. The development of new intracerebral hematoma in follow-up CT scans were more common in the FFP group than the N/S group (p=0.012). Both groups showed similar frequency of poor outcome (p=0.343). The mortality was significantly more common in the FFP group than in the N/S group (63% versus 35%, p=0.006). CONCLUSION: The result of this study revealed that early empirical infusion of FFP in patients with severe head injury may lead to adverse effects, such as an increase in the frequency of DTICH and an increase in the mortality.

Extramedullary hematopoiesis with spinal cord compression in beta-thalassemia intermedia.

Spinal cord compression due to extramedullary hematopoiesis is a rare manifestation of thalassemia. We present a 28-year-old woman with beta-thalassemia intermedia and progressive paraparesis. She had a thoracic extradural extramedullary mass lesion on MRI. She improved after receiving multiple transfusions. Clinical awareness of this phenomenon with early treatment is essential for a successful outcome.

Improving communication between the physician and the COPD patient: an evaluation of the utility of the COPD Assessment Test in primary care.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. It is now considered a systemic inflammatory syndrome and is associated with important comorbidities. In addition to spirometry for evaluating the severity of airflow obstruction, an instrument is required for comprehensive assessment of the disease. The COPD Assessment Test (CAT) is a simple and valid tool for evaluating patient symptoms. The CAT can improve patient-physician communication during routine clinical visits and is useful for assessing functional status and response to treatment. The CAT has a strong correlation with other health status questionnaires, such as the St George's Respiratory Questionnaire. The main advantages of the CAT are its thorough coverage of the important clinical aspects of disease burden and the shorter time involved in completing it. The aim of this paper is to review the role of the CAT, to compare it with other health-related quality of life questionnaires in the assessment and management of COPD patients, and to emphasize the importance of patient-physician communication in the management of patients with the disease.

COPD assessment test (CAT): simple tool for evaluating quality of life of chemical warfare patients with chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is one of the serious late pulmonary complications caused by sulphur mustard exposure. Health status evaluations of chemical warfare patients with COPD are important to the management of these patients. The aim of this study was to determine the efficacy of the COPD assessment test (CAT) in evaluating the health-related quality of life (HRQOL) of chemical warfare patients with COPD. METHODS: Eighty-two consecutive patients with stable COPD were enrolled in this study. All subjects were visited by one physician, and the HRQOL was evaluated by the CAT and St. George Respiratory Questionnaires (SGRQs). In addition, a standard spirometry test, 6-min walk distance test and pulse oxymetry were conducted. The severity of the COPD was determined using Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging and the body mass index, obstruction, dyspnoea and exercise (BODE) index. RESULTS: The mean age of the patients was 47.30 ± 7.08 years. The mean CAT score was 26.03 ± 8.28. Thirty-five (43%) patients were in CAT stage 3. There were statistically significant correlations between the CAT and the SGRQ (r = 0.70, P = 0.001) and the BODE index (r = 0.70, P = 0.001). A statistically significant inverse correlation was found between the CAT score and the forced expiratory volume in 1 s (r = -0.30, P = 0.03). CONCLUSIONS: Our results demonstrated that the CAT is a simple and valid tool for assessment of HRQOL in chemical warfare patients with COPD and can be used in clinical practice.

The assessment of undergraduate medical students' satisfaction levels with the objective structured clinical examination.

BACKGROUND: The objective structured clinical examination (OSCE) has been introduced as an efficient method for the assessment of medical students. OBJECTIVES: The aim of the present study was to determine the satisfaction level of undergraduate medical students of internal medicine department with the OSCE. MATERIALS AND METHODS: This was a descriptive cross-sectional study, performed on all available undergraduate students at the end of their internal medicine training period in Mashhad University of Medical Sciences. The students responded to 15 multiple-choice questions with confirmed validity and reliability. RESULTS: The majority of the students (94.5%) had a positive attitude toward the OSCE and mentioned that the OSCE format was a more appropriate type of exam than other methods of testing; however, 79.1% thought that the OSCE format was stressful. In addition, the participants' sex had no effect on their level of satisfaction with the examination. Likewise, there was no significant correlation between their level of satisfaction and their age, marital status, or lack of previous experience with this type of exam. CONCLUSIONS: If the exam standards are met and a uniform dispersion of the scientific content is maintained, the OSCE method of assessment can be recommended as an efficient and applicable method for assessing medical students.

The management of bronchus intermedius complications after lung transplantation: a retrospective study.

BACKGROUND: Airway complications following lung transplantation remain a significant cause of morbidity and mortality. The management of bronchial complications in Bronchus Intermedius (BI) is challenging due to the location of right upper bronchus. The aim of this study was to analyze the results of BI Montgomery T-tube stent in a consecutive patients with lung transplantations. METHODS: Between January 2007 and December 2010, 132 lung transplantations were performed at Foch Hospital, Suresnes, France. All the patients who had BI Montgomery T-tube after lung transplantation were included in this retrospective study. The demographic and interventional data and also complications were recorded. RESULTS: Out of 132 lung transplant recipients, 12 patients (9 male and 3 female) were entered into this study. The indications for lung transplantation were: cystic fibrosis 8 (67%), emphysema 3 (25%), and idiopathic pulmonary fibrosis 1 (8%). Most of the patients (83%) had bilateral lung transplantation. The mean interval between lung transplantation and interventional bronchoscopy was 11.5 ± 9.8 (SD) months. There was bronchial stenosis at the level of BI in 7 patients (58.3%). The Montgomery T-tube number 10 was used in 9 patients (75%). There was statistically significant difference in Forced Expiratory Volume in one second (FEV1) before and after stent placement (p = 0.01). The most common complication after stent placement was migration (33%). CONCLUSION: BI complications after lung transplantation are still a significant problem. Stenosis or malacia following lung transplantation could be well managed with modified Montgomery T-tube.

Interleukin-6 and airflow limitation in chemical warfare patients with chronic obstructive pulmonary disease.

OBJECTIVES: Chronic obstructive pulmonary disease (COPD) is one of the main late complications of sulfur mustard poisoning. The aim of this study was to evaluate serum levels of interleukin (IL)-6 in war veterans with pulmonary complications of sulfur mustard poisoning and their correlation with severity of airways disease. METHODS: Fifty consecutive patients with sulfur mustard poisoning and stable COPD, and of mean age 46.3 ± 9.18 years were enrolled in this study. Thirty healthy men were selected as controls and matched to cases by age and body mass index. Spirometry, arterial blood gas, six- minute walk test, BODE (body mass index, obstruction, dyspnea, and exercise capacity), and St George's Respiratory Questionnaire about quality of life were evaluated. Serum IL-6 was measured in both patient and control groups. RESULTS: Fifty-four percent of patients had moderate COPD. Mean serum IL-6 levels were 15.01 ± standard deviation (SD) 0.61 pg/dL and 4.59 ± 3.40 pg/dL in the case and control groups, respectively (P = 0.03). There was a significant correlation between IL-6 levels and Global Initiative for Chronic Obstructive Lung Disease stage (r = 0.25, P = 0.04) and between IL-6 and BODE index (r = 0.38, P = 0.01). There was also a significant negative correlation between serum IL-6 and forced expiratory volume in one second (FEV(1), r = -0.36, P = 0.016). CONCLUSION: Our findings suggest that serum IL-6 is increased in patients with sulfur mustard poisoning and COPD, and may have a direct association with airflow limitation.

Highly sensitive C-reactive protein levels in Iranian patients with pulmonary complication of sulfur mustard poisoning and its correlation with severity of airway diseases.

BACKGROUND: Sulfur mustard (SM) is a chemical warfare agent that can cause serious pulmonary complications. This study was designed to determine serum highly sensitive C-reactive protein (hs-CRP) and evaluate its correlation with lung function parameters in patients with chronic obstructive pulmonary disease (COPD) due to SM poisoning. METHODS: Fifty consecutive SM patients with stable COPD and a mean age 46.3 +/- 9.18 years were enrolled in this cross sectional study. Thirty healthy men were selected as controls. Lung function parameters were evaluated. Serum hs-CRP by immunoturbidometry assay was measured in both the patients and controls. RESULTS: In the case group, the mean forced expiratory volume in one second (FEV1) was 2.14 +/- 0.76 L (58.98% +/- 17.51% predicted). The mean serum hs-CRP was 9.4 +/- 6.78 SD and 3.9 +/- 1.92 SD mg/L in the cases and controls, respectively, with significant statistical differences (p < .001). There was negative correlation between the serum hs-CRP and FEV1 levels (p = .01). The serum hs-CRP levels were also correlated with Global Initiative for Chronic Obstructive Lung disease (GOLD) stages (r = .45, p < .001). CONCLUSIONS: Our findings suggest that the serum hs-CRP level is increased in SM patients with COPD and may have a direct correlation with disease severity. It may then be used as a marker for the severity of COPD in patients with SM poisoning.