Barriers to adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease in Iran: a descriptive qualitative study.

OBJECTIVES: Chronic obstructive pulmonary disease is a chronic disease with numerous complications. Therefore, its effective management depends on home-based pulmonary rehabilitation. The effectiveness of home-based pulmonary rehabilitation programmes in turn depends on patient adherence to them. The aim of this study was to explore the barriers to adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease. DESIGN: Qualitative descriptive design. SETTING: The lung care wards of Al-Zahra and Khorshid teaching hospitals and the comprehensive lung care clinic of Khorshid hospital, Isfahan, Iran. PARTICIPANTS: Participants patients with chronic obstructive pulmonary disease (n=20), their family caregivers (n=15) and healthcare providers (n=14) recruited via purposive sampling. RESULTS: The five main categories of the barriers to adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease were patient-related barriers, caregivers' caregiving burden, limited support for patients, healthcare providers' limited professional competence and ineffective home-based pulmonary rehabilitation planning. CONCLUSION: Different and complex factors related to patients, families and healthcare providers can affect adherence to home-based pulmonary rehabilitation among patients with chronic obstructive pulmonary disease. Healthcare authorities can use the findings of this study to develop strategies to support patients with chronic obstructive pulmonary disease and their family caregivers and thereby reduce the physical and mental complications of Chronic obstructive pulmonary disease.

Thalidomide for the Treatment of COVID-19 Pneumonia: A Randomized Controlled Clinical Trial.

Background: Coronavirus disease 2019 has become a public health concern with a high number of fatalities. Thalidomide can target inflammatory mediators and decrease inflammation in SARS-CoV-2. Materials and Methods: An open-label, randomized controlled trial was conducted on patients with compatible lung high-resolution computed tomography scan for COVID-19 pneumonia and moderate involvement. Childbearing-age women were excluded. A total of 20 patients in the control group receiving usual treatment were compared with 26 patients in the case group who in addition to the same regimen also received thalidomide. The primary outcome was time for clinical recovery (TTCR) and intensive-care unit (ICU) admission. Results: From April 25 to August 8, 2020, based on the inclusion criteria, 47 patients were assigned to the study. Patients receiving thalidomide had a mean TTCR of days 5.5 (95% confidence interval [CI], 0.7-10.3), as compared with days 5.3 (95% CI, 1.7-8.9) with control (odds ratio 0.01; 95% CI, -1.58-1.59, P = 0.807). The incidence of ICU admission was 27% in the thalidomide group compared with 20% in the control group (odds ratio 3.89; 95% CI, 0.55-27.4, P = 0.425). The mean length of stay in hospital in both groups was 10 days. Progressive improvement in respiratory rate, fever, and O2 saturation during the study was seen in both groups without a significant difference between the thalidomide and control group (P > 0.05). Conclusion: This study investigated the effects of thalidomide to treat moderate COVID-19 clinical outcomes. The results established that this drug regimen did not add more effect to usual treatment for moderate COVID-19 pneumonia.

Mobile Phone App-Based or Face-to-Face Pulmonary Rehabilitation in COVID-19 Survivors.

Background: Pulmonary Rehabilitation (PR) is recommended as a standard, effective, and important treatment for COVID-19 survivors who remain symptomatic after the acute phase. Therefore, we aimed to compare the effect of mobile phone-based PR application with face-to-face PR on the quality of life, anxiety, depression, and daily life activities of COVID-19 survivors. Materials and Methods: A quasi-experimental was conducted on 65 COVID-19 survivors during 2022. Convenient sampling was done based on the inclusion criteria. The intervention group (n = 31) received PR through a mobile phone application, and the control group (n = 34) received face-to-face PR. Data were collected before and after the intervention in both groups using a demographic information questionnaire, SF-12, the hospital anxiety and depression scale, and Barthel scale. For all tests, a maximum error of 5% was considered. Results: The two studied groups had no statistically significant difference with respect to all the investigated variables at baseline (p > 0.05). After the intervention, the mean anxiety and depression score of the patients in the control group was significantly lower than the intervention group (t = -3.46, f = 63, p = 0.01). After our intervention, there was no statistically significant difference in the mean quality of life and daily life activity scores between the two groups (t = -0.68, f = 63, p > 0.05). Conclusions: The application of PR does not show a statistically significant difference in terms of improving the quality of life and daily activities compared with the face-to-face method; we suggest that the PR application be used as a cost-effective method when face-to-face PR is not possible.

Short-term Pulmonary Rehabilitation after Recovering from Severe COVID-19.

Background: Patients with severe COVID-19 suffer from various problems such as impaired lung function, decreased exercise capacity, mental disorders, and reduced quality of life. This study aimed to evaluate the effectiveness of short-term pulmonary rehabilitation in patients recovering from severe COVID-19. Methods: The present study was a retrospective cohort study. This study was conducted in 2021 on 92 patients with severe COVID-19 who met the inclusion criteria. Inter-professional pulmonary rehabilitation sessions were performed for 3 weeks, twice a week (six sessions in total), for this group of patients, which included physical exercises, educational activities, and other health-related services (counseling and psychotherapy). Outcomes assessed included a 6-min walk test, the score of the Hospital Anxiety and Depression Scale, and the SF-12 Quality of Life Questionnaire, which were completed before and after pulmonary rehabilitation. Data analysis was performed using analytical and descriptive statistics. Results: The statistical analyses showed that 60.86% of patients participating in the study were male and 39.14% were female, and the mean age of patients was 54.9 ± 12.3 years. The findings also showed that the average distance traveled in the 6-min walk test before pulmonary rehabilitation was 289.2174 ± 130.5 m; however, after the intervention, this rate reached 343.0870 ± 103.5 m, which demonstrated a statistically significant difference (P = 0.00). Also, significant changes were observed in anxiety and depression, the ability to perform daily activities, and the physical health of patients before and after the intervention (P < 0.05). Conclusions: Short-term pulmonary rehabilitation is a safe and useful treatment without side effects that can be effective in reducing anxiety and depression, increasing the ability to perform daily activities and exercise capacity, and consequently, improving the quality of life of patients recovering from severe COVID-19.

Retroperitoneal hematoma in patients with COVID-19 infection during anticoagulant therapy: A case series and literature review.

Due to the hypercoagulable status of patients with severe COVID-19 infection, anticoagulants are often used to prevent thrombosis. However, these agents may cause bleeding events such as retroperitoneal hematoma (RPH). We report here on six patients with COVID-19 who developed RPH during treatment. Early evidence of bleeding led to confirmatory diagnosis with imaging. Four patients recovered with supportive treatment (IV fluids and blood transfusions) and two patients recovered by angioembolization. RPH should be considered in COVID patients on anticoagulants as soon as haemoglobin or blood pressure falls. Further studies are required to provide guidance and recommendations on use of anticoagulants in critically ill patients with COVID-19.

Hemoperfusion in patients with severe COVID-19 respiratory failure, lifesaving or not?

BACKGROUND: The new coronavirus outbreak quickly filled hospital beds and stunned the world. Intensive care is required for 5% of patients, and the mortality rate for critically ill patients is 49%. The "cytokine storm" is considered as the main cause of pathogenesis for coronavirus disease-19 (COVID-19)-related respiratory failure, hemoperfusion may be a modality for treatment of disease. MATERIALS AND METHODS: Thirty-seven an patients with positive real-time polymerase chain reaction for SARStions2 in an upper respiratory tract sample or typical chest computed tomography lesion were eligible for this case-control study. Patients meeting the criteria for hemoperfusion including clinical and laboratory indices, were evaluated for outcomes such as hospitalization length and mortality. Patients were divided into three groups, i.e., patients who received hemoperfusion without a need for mechanical ventilation (MV), patients who received hemoperfusion before MV, and patients who received hemoperfusion after MV. RESULTS: Among 37 patients with COVID-19 respiratory failure, 32% were female with a mean age of 55.54 (standard deviation 14.1) years. There was no statistically significant difference between the three groups in terms of length of hospital stay and intensive care unit (ICU) stay (P-tayns: 0.593 and 0.243, respectively, confidence interval [CI]: 95%). Heart rate, respiratory rate, PaO2/FIO2, high-sensitivity C-reactive protein, and ferritin significantly improved after the application of hemoperfusion in all groups (P < 0.05, CI: 95%). CONCLUSION: It seems that applying hemoperfusion in the inflammatory phase of the disease, especially before the intubation, reduce the need for MV. However, hemoperfusion does not have any impacts on the duration of hospital and ICU stay.

Exploring the barriers to pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a qualitative study.

BACKGROUND: The complexity of chronic obstructive pulmonary disease (COPD) and its different physical, mental, familial, occupational, and social complications highlight the necessity of pulmonary rehabilitation (PR) for afflicted patients. However, PR for patients with COPD usually faces some barriers. The aim of this study was to explore the barriers to PR for patients with COPD. METHODS: This qualitative descriptive study was conducted in January 2019 to October 2020. Participants were 19 patients with COPD, 11 family caregivers of patients with COPD, and 12 healthcare providers, who all were recruited purposively from two teaching hospitals in Isfahan, Iran. Data were collected through semi-structured interviews and were analyzed through conventional content analysis. RESULTS: The barriers to PR for patients with COPD fell into three main categories, namely barriers related to patients and their families, inefficiency of PR services, and inappropriate organizational context for PR. Each category had four subcategories, namely patients' and families' lack of knowledge, complexity and chronicity of COPD, heavy financial burden of COPD, patients' frustration and discontinuation of PR, lack of patient-centeredness, lack of coordination in PR team, inadequate professional competence of PR staff, lack of a holistic approach to PR, limited access to PR services, inadequate insurance for PR services, ineffective PR planning, and discontinuity of care. CONCLUSION: PR for patients with COPD is a complex process which faces different personal, familial, social, financial, organizational, and governmental barriers. Strategies for managing these barriers are needed in order to improve the effectiveness and the quality of PR services for patients with COPD.

Fatal disseminated aspergillosis in an immunocompetent patient with COVID-19 due to Aspergillus ochraceus.

Aspergillus infection is a well-known complication of severe influenza and severe acute respiratory syndrome coronavirus (SARS-CoV), and these infections have been related with significant morbidity and mortality even when appropriately diagnosed and treated. Recent studies have indicated that SARS-CoV-2 might increase the risk of invasive pulmonary aspergillosis (IPA). Here, we report the first case of Aspergillus ochraceus in a SARS-CoV-2 positive immunocompetent patient, which is complicated by pulmonary and brain infections. Proven IPA is supported by the positive Galactomannan test, culture-positive, and histopathological evidence. The patient did not respond to voriconazole, and liposomal amphotericin B was added to his anti-fungal regimen. Further studies are needed to evaluate the prevalence of IPA in immunocompetent patients infected with SARS-CoV-2. Consequently, testing for the incidence of Aspergillus species in lower respiratory secretions and Galactomannan test of COVID-19 patients with appropriate therapy and targeted anti-fungal therapy based on the primary clinical suspicion of IPA are highly recommended.

Coronavirus Disease-2019 Pneumonia and Pulmonary Embolism: Presentation of Four Cases.

Since the beginning of the Coronavirus Disease-2019 (COVID-19) outbreak, elevated D-dimer levels as an acute-phase reactant have been reported in some patients. Additionally, the patients with pneumonia are at increased risk of developing thromboembolic events. Diagnosing acute pulmonary embolism and deep vein thrombosis can be challenging in SARS-CoV2-positive patients. Here, we report four patients with COVID-19 pneumonia to highlight the possibility of acute thromboembolism in these patients. The physicians should be aware of this complication and even consider prophylactic anticoagulant therapy in proper clinical settings. How to cite this article: Alikhani F, Aalinezhad M, Haji Rezaei M, Akbari P, Hashemi M. Coronavirus Disease-2019 Pneumonia and Pulmonary Embolism: Presentation of Four Cases. Indian J Crit Care Med 2020;24(9):873-876.

Structural Assessment of Hydrogen Bonds on Methylpentynol-Azide Clusters To Achieve Regiochemical Outcome of 1,3-Dipolar Cycloaddition Reactions Using Density Functional Theory.

This study was focused on the geometries and properties of the structural isomers obtained from a random walk of methylpentynol-HN3 clusters. The theoretical aspects of hydrogen bonding effects on the discussed 1,3-dipolar cycloaddition (1,3-DC) reactions [between methylpentynol (a) as a dipolarophile and azide (b) as a 1,3-dipole] have shown regioselective output concepts. The dipolarophile methylpentynol (a) was applied for the treatment of insomnia. Both methylpentynol (a) and azide (b) can be H-bond acceptor and H-bond donor agents. Because of this trait of them, structures of H-bonding arrays (c-f) and methylpentynol-azide clusters (g-m) can be probable. In this work, regioselectivity of the 1,3-DC reaction [between methylpentynol (a) as a dipolarophile and azide (b) as a 1,3-dipole] was determined based on these structures (c-m) using density functional theory (DFT). The energy levels of the reactants (a and b) and the structures of H-bonding arrays (c-f), methylpentynol-azide clusters (g-m), transition states, and products (1 and 2) were studied, and also, the free energies of the reaction (Δr G and ΔG #, in kcal mol-1) and rate constants were determined using Eyring's equation (k). Structural data were calculated and obtained by the DFT/B3LYP method. Seven different basis sets have been used to obtain the most appropriate results from comparison of data.

The utility of elastography during EBUS-TBNA in a population with a high prevalence of anthracosis.

BACKGROUND: Ultrasound elastography, is a pioneer sonographic modality that is conducted during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in order to increase the accuracy of sampling location. The current study aims to evaluate the usefulness of elastography during EBUS-TBNA in a population with a high prevalence of anthracosis. METHODS: This prospective single-blinded study was performed on 69 lymph nodes (LNs) of patients with mediastinal lymphadenopathy undergoing EBUS-TBNA and EBUS-elastography from October 2017 to July 2018. The stiffness level of the tissue was translated into a color to demonstrate the hardness of tissue. Blue and total areas of each section were measured to calculate the hardness of each LN. RESULTS: Sixty-nine LNs were evaluated by elastography. Twenty percent of LNs were malignant. There was a statistical difference between malignant and non-malignant nodes based on color dominancy (P = 0.032). However, with the exclusion of anthracosis nodes from the analysis, the difference was more significant (P < 0.001). Moreover, when the blue dominancy was used as the predictor of malignancy or anthracosis, the results showed a significant correlation (P < 001). CONCLUSION: The usefulness of elastography in selecting the hardest area of tissue that is appropriate for diagnosing diseases has been proven previously. Since in countries with a high prevalence of anthracosis, blue color achieved using elastography predicts either malignancy or anthracosis so, cases with blue dominancy of LNs in elastography and the white color in the EBUS-TBNA indicate anthracosis-caused calcification should be reconsidered.

Real Time Polymerase Chain Reaction for Hepatitis B Screening in Donor Corneas in the Central Eye Bank of Iran.

PURPOSE: The aim of this study was to report the results of the use of real-time polymerase chain reaction (PCR) for the diagnosis of hepatitis B virus (HBV) infection in cornea donors at the Central Eye Bank of Iran. METHODS: Between 2014 and 2016, all cornea donors that had negative screening serologic results for hepatitis B (HB) surface antigen, HB surface antibody (Ab), hepatitis C virus Ab, human immune deficiency virus Ab, human T-cell leukemia virus Ab, and syphilis, and positive serology for HB core Ab were subjected to real-time PCR with a detection limit of 400 IU/mL to identify HBV DNA. Positive results for HBV DNA were considered occult HBV infections in these donors. RESULTS: Over the 3-year period, 122 out of 10448 cornea donors had negative screening serologic tests outside of HB core Ab. Of which, 90 cases were subjected to real-time PCR. Occult HBV was detected in 11 cases (12.2%), resulting in the rejection of the corresponding corneas. The remaining 79 cases (87.8%) had negative results for HBV DNA and the corresponding corneas were used for transplantation. CONCLUSION: Implementation of PCR for the detection of occult HBV in cornea donors is necessary to not only increase the security level of cornea donation but also minimize the rejection rate of donors that have isolated HB core Ab reactivity.

Assessemnt of nasal bone in first trimester screening for chromosomal abnormalities in Khuzestan.

BACKGROUND: Fetal nasal bone assessment is a non-invasive procedure that helps provide even greater assurance to patients undergoing their first trimester risk assessment for aneuploidies. Absence or presence of this factor is different in some races. OBJECTIVE: The study was aimed to evaluate nasal bone in the first trimester of pregnancy in the indigenous population of Khuzestan Province, and to monitor its value in the diagnosis of chromosomal abnormalities. MATERIALS AND METHODS: This study was conducted on 2314 pregnant women between 17-43 years old who referred for first trimester screening for chromosomal abnormalities. Gestational age was between 11-13w + 6 days. Nuchal translucency (NT), fetal heart rate (FHR), crown rump length (CRL), and maternal age and maternal blood serum factors (Free HCG) and pregnancy-associated plasma protein-A (PAPP-A) and nasal bone were assessed. Finally the risk of trisomies was calculated. The statistical tests are based on the relationship between chromosomal abnormality and the presence or absence of the nasal bone. RESULTS: In 114 cases we could not examine the nasal bone. Also, in 20 cases missed abortion happened without knowing the karyotype. 2173 cases were delivered normal baby, and in seven cases chromosomal abnormalities were diagnosed. Nasal bone was absent in all three cases with trisomy 21 and six of 2173 cases with normal phenotype (0.3%). With use of the Fisher exact test (p=0.0001), a significant correlation was found between the absence of the nasal bone and the risk of chromosomal abnormality. CONCLUSION: Inclusion of the nasal bone in first-trimester combined screening for aneuploidies achieves greater detection rate especially in Down syndrome.

Various confocal scan features of cysts and trophozoites in cases with Acanthamoeba keratitis.

PURPOSE: To describe the various confocal scan features of cysts and trophozoites in patients with Acanthamoeba keratitis and to specify the associated findings. METHODS: In a retrospective study of cases between June 2005 and June 2010, we reviewed all the recorded confocal scan images of patients given a high index in regards to clinical suspicion of Acanthamoeba keratitis, in order to specify the various morphometric and morphologic features of Acanthamoeba cysts and trophozoites and to characterize the associated findings in such cases. RESULTS: Confocal scan images of 170 eyes from 170 patients were reviewed. Bilayered, target-shaped, coffee-bean and rod-shaped appearances of the cysts were observed in 100%, 82.9%, 36.4%, and 17.5% of cases, respectively. Single file arrangement of the cysts was noticed in 22 cases. The mean size of the cysts was 18.9 µm (range 10-39.6). In all cases, trophozoites were observed as pear-shaped or irregularly wedge-shaped structures, some surrounded by a brilliant halo and some exhibiting fine pseudopodia-like extensions, with mean size of 30.2 µm (range 19.2-55.6). Keratoneuritis and the anterior stromal honeycomb pattern were seen in 28.2% and 5.9% of cases, respectively. CONCLUSIONS: To our knowledge, this is the largest case-series study on confocal scan features of Acanthamoeba cysts and trophozoites in cases with clinical diagnosis of Acanthamoeba keratitis specifying the morphologic and morphometric criteria of this infectious organism and the associated findings.

Should We Look for Celiac Disease among all Patients with Liver Function Test Abnormalities?

BACKGROUND: Celiac disease (CD) has been found in up to 10% of the patients presenting with unexplained abnormal liver function tests (LFT). As there is no precise data from our country in this regard, we investigated the prevalence of CD in patients presenting with abnormal LFT. METHODS: From 2003 to 2008, we measured IgA anti-tissue transglutaminase (t-TG) antibody (with ELISA technique) within the first-level screening steps for all patients presenting with abnormal LFT to three outpatient gastroenterology clinics in Isfahan, IRAN. All subjects with an IgA anti-tTG antibody value of >10 µ/ml (seropositive) were undergone upper gastrointestinal endoscopy and duodenal biopsy. Histopathological changes were assessed according to the Marsh classification. CD was defined as being seropositive with Marsh I or above in histopathology and having a good response to gluten free diet (GFD). RESULTS: During the study, 224 patients were evaluated, out of which, 10 patients (4.4%) were seropositive for CD. Duodenal biopsies were performed in eight patients and revealed six (2.7%) cases of Marsh I or above (four Marsh IIIA, two Marsh I), all of them had good response to GFD. The overall prevalence of CD among patients with hypertransaminasemia, autoimmune hepatitis, and cryptogenic cirrhosis was determined as 10.7% (3/28), 3.4% (2/59), and 5.3% (1/19), respectively. CONCLUSION: Serological screening with IgA anti-tTG antibody test should be routinely performed in patients presenting with abnormal LFT and especially those with chronic liver diseases including hypertransaminasemia, autoimmune hepatitis, and cryptogenic cirrhosis.

How frequent is celiac disease among epileptic patients?

BACKGROUND: A variety of neurological disorders have been reported in association with celiac disease (CD) including epilepsy, ataxia, neuropathy and multifocal leucoencephalopathy. The purpose of this study was to assess the prevalence of CD among epileptic patients. METHODS: Our study population consisted of 108 consecutive unexplained epileptic patients from Epilepsy Clinics. Patients who were able to give informed consent were invited to undergo screening for CD in a gastroenterology clinic. The diagnosis of CD was determined by IgA anti-tissue transglutaminase (t-TG) antibodies and by small intestine biopsy. Histopathologic changes were interpreted according to the Marsh classification. RESULTS: A total of 108 consecutive epileptic patients (72 females, 36 males) ranging from 2-64 years (mean: 23.44, SD: 12.1) were studied. Positive IgA anti t-TG were detected in 4 of 108 epileptic patients (3.7%), while the known prevalence of CD in the study area was 0.6%.The intestinal biopsy confirmed the diagnosis of CD in three patients and was interpreted as Marsh I. In the other patient, small intestinal biopsy indicated only slightly increased number of intraepithelial lymphocytes. There was a significant difference between patients with CD and without CD for two symptoms: diarrhea and aphtous lesions (p<0.05). CONCLUSION: Prevalence of CD was increased among patients with epilepsy of unknown etiology. It is important to investigate CD in any patient with idiopathic epilepsy even in the absence of digestive symptoms.

Diagnostic accuracy of IgA anti-tissue transglutaminase in patients suspected of having coeliac disease in Iran.

BACKGROUND AND AIM: As there are little data about the sensitivity of the IgA anti-tissue transglutaminase (IgA anti-tTG) antibody test in the clinical practice setting, we evaluated the sensitivity of this serologic test in a group of patients who were suspected of having coeliac disease and had serologic testing performed at commercial laboratories. PATIENTS AND METHODS: The study was performed at Poursina Hakim Research Institute in Isfahan-Iran. A total number of 350 consecutive patients were enrolled in our study. They were divided into 3 groups: classical mode of presentation, atypical mode of presentation and patients with non specific prolonged gastrointestinal symptoms. Upper gastrointestinal endoscopy, histopathologic examination of biopsies from the second part of duodenum and serologic evaluation were performed for every patient. Biopsy specimens were evaluated according to Marsh (1992, revised in 1997). RESULTS: The overall sensitivity and specificity of IgA anti-tTG antibody were 38% and 98%. The positive and negative predictive values for the anti-tTG antibodies were 57% and 96%, respectively. The sensitivity was 80% in patients with Marsh IIIC. CONCLUSION: In contrast to other reports suggesting a diagnostic accuracy of more than 90% for anti-tTG antibody in coeliac disease patients, our data showed that we are still far from an ideal screening serologic tool which can rely on the antibody test as the sole way of identifying patients with coeliac disease. This could result in many missed diagnoses, in particular in patients with lesser degrees of Marsh classification.