Clinical standards for the diagnosis and management of asthma in low- and middle-income countries

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

Issue 1 - "Update on adverse respiratory effects of outdoor air pollution" Part 2): Outdoor air pollution and respiratory diseases: Perspectives from Angola, Brazil, Canada, Iran, Mozambique and Portugal

OBJECTIVE

To analyse the GARD perspective on the health effects of outdoor air pollution, and to synthesise the Portuguese epidemiological contribution to knowledge on its respiratory impact.

RESULTS

Ambient air pollution has deleterious respiratory effects which are more apparent in larger, densely populated and industrialised countries, such as Canada, Iran, Brazil and Portugal, but it also affects people living in low-level exposure areas. While low- and middle-income countries (LMICs), are particularly affected, evidence based on epidemiological studies from LMICs is both limited and heterogeneous. While nationally, Portugal has a relatively low level of air pollution, many major cities face with substantial air pollution problems. Time series and cross-sectional epidemiological studies have suggested increased respiratory hospital admissions, and increased risk of respiratory diseases in people who live in urban areas and are exposed to even a relatively low level of air pollution.

CONCLUSIONS

Adverse respiratory effects due to air pollution, even at low levels, have been confirmed by epidemiological studies. However, evidence from LMICs is heterogeneous and relatively limited. Furthermore, longitudinal cohort studies designed to study and quantify the link between exposure to air pollutants and respiratory diseases are needed. Worldwide, an integrated approach must involve multi-level stakeholders including governments (in Portugal, the Portuguese Ministry of Health, which hosts GARD-Portugal), academia, health professionals, scientific societies, patient associations and the community at large. Such an approach not only will garner a robust commitment, establish strong advocacy and clear objectives, and raise greater awareness, it will also support a strategy with adequate measures to be implemented to achieve better air quality and reduce the burden of chronic respiratory diseases (CRDs).

Knowledge, attitude, and practice among staff associated with Human Papillomavirus Vaccine of young children in Iran

INTRODUCTION

This study aimed to evaluate knowledge, attitudes, practice associated with Human Papillomavirus (HPV) Vaccine for Young Children among lecturers and health staffs of Shahid Beheshti University of Medical Sciences (SBMU).

METHOD

This was a cross-sectional study with 220 adults from five different specialties, randomly selected. Data was collected using 45-item questionnaire on knowledge (12- item), attitude (18-item) and practice (15-item) (KAP) about HPV. The demographic questionnaire included information on age, gender, level of education, occupation, and marital status. Content validity was calculated by content validity ratio (CVR) and content validity index (CVI). Reliability was evaluated using test-retest and by Cronbach's Alpha coefficient, internal consistency was calculated values >0.81 which considered as satisfactory.

RESULTS

The mean age of the studied population was 37.70± 8.07 (23-67) years. Of the 220 participants, 80 (36.4%) were males and 140 (63.6%) were females. In evaluating KAP in the men and women, the mean and standard deviation of knowledge were estimated at good level and one-way ANOVA analysis showed significant differences between women and men (p=0.019). There was no significant difference in men and women related to attitude (p=0.92) and practice (p=0.38).

CONCLUSION

The KAP about HPV among participants was significantly higher at good levels compared to average levels. Women's knowledge was significantly higher than men. Attitude and practice could have been higher because there was consensus to the usage of vaccine among the specialists to prevent HPV.

Correlation between work impairment, scores of rhinitis severity and asthma using the MASK-air® App

BACKGROUND

In allergic rhinitis, a relevant outcome providing information on the effectiveness of interventions is needed. In MASK-air (Mobile Airways Sentinel Network), a visual analogue scale (VAS) for work is used as a relevant outcome. This study aimed to assess the performance of the work VAS work by comparing VAS work with other VAS measurements and symptom-medication scores obtained concurrently.

METHODS

All consecutive MASK-air users in 23 countries from 1 June 2016 to 31 October 2018 were included (14 189 users; 205 904 days). Geolocalized users self-assessed daily symptom control using the touchscreen functionality on their smart phone to click on VAS scores (ranging from 0 to 100) for overall symptoms (global), nose, eyes, asthma and work. Two symptom-medication scores were used: the modified EAACI CSMS score and the MASK control score for rhinitis. To assess data quality, the intra-individual response variability (IRV) index was calculated.

RESULTS

A strong correlation was observed between VAS work and other VAS. The highest levels for correlation with VAS work and variance explained in VAS work were found with VAS global, followed by VAS nose, eye and asthma. In comparison with VAS global, the mCSMS and MASK control score showed a lower correlation with VAS work. Results are unlikely to be explained by a low quality of data arising from repeated VAS measures.

CONCLUSIONS

VAS work correlates with other outcomes (VAS global, nose, eye and asthma) but less well with a symptom-medication score. VAS work should be considered as a potentially useful AR outcome in intervention studies.

Cigarette smoking in patients newly diagnosed with pulmonary tuberculosis in Iran

BACKGROUND

The association between pulmonary tuberculosis (PTB) and tobacco smoke has been verified by most studies on the subject; figures from different countries for the prevalence of smoking among PTB patients vary.

OBJECTIVE

To assess the prevalence of and factors associated with smoking among TB patients in Iran.

DESIGN

In this cross-sectional study, subjects were included on a first-come, first-served basis from among newly diagnosed PTB patients using a multistage cluster sampling method during 2012-2014. Data were collected during face-to-face interviews and a questionnaire was used to gather information on smoking habits.

RESULTS

Of 1127 newly diagnosed PTB patients included in the study (mean age 50.0 ± 19.8 years), 228 (20.2%) were daily smokers, 20 (1.8%) were occasional smokers and 93 (8.9%) had quit before diagnosis. Simultaneous drug use (P < 0.001, OR 75.21), increasing age (P = 0.001), being single (P < 0.001, OR 16.95), being an Iranian national (P < 0.001, OR 6.26) and living in a rural area (P < 0.001, OR 5.85) were found to be independent risk factors for smoking in study patients.

CONCLUSION

The prevalence of smoking among PTB patients in Iran is relatively high. It is therefore necessary to include smoking cessation interventions in the National TB Programme.

ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA—disseminated and implemented in over 70 countries globally—is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Scaling up strategies of the chronic respiratory disease programme of the European Innovation Partnership on Active and Healthy Ageing (Action Plan B3: Area 5)

Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) focuses on the integrated care of chronic diseases. Area 5 (Care Pathways) was initiated using chronic respiratory diseases as a model. The chronic respiratory disease action plan includes (1) AIRWAYS integrated care pathways (ICPs), (2) the joint initiative between the Reference site MACVIA-LR (Contre les MAladies Chroniques pour un VIeillissement Actif) and ARIA (Allergic Rhinitis and its Impact on Asthma), (3) Commitments for Action to the European Innovation Partnership on Active and Healthy Ageing and the AIRWAYS ICPs network. It is deployed in collaboration with the World Health Organization Global Alliance against Chronic Respiratory Diseases (GARD). The European Innovation Partnership on Active and Healthy Ageing has proposed a 5-step framework for developing an individual scaling up strategy: (1) what to scale up: (1-a) databases of good practices, (1-b) assessment of viability of the scaling up of good practices, (1-c) classification of good practices for local replication and (2) how to scale up: (2-a) facilitating partnerships for scaling up, (2-b) implementation of key success factors and lessons learnt, including emerging technologies for individualised and predictive medicine. This strategy has already been applied to the chronic respiratory disease action plan of the European Innovation Partnership on Active and Healthy Ageing.

MACVIA-ARIA Sentinel NetworK for allergic rhinitis (MASK-rhinitis): the new generation guideline implementation

Several unmet needs have been identified in allergic rhinitis: identification of the time of onset of the pollen season, optimal control of rhinitis and comorbidities, patient stratification, multidisciplinary team for integrated care pathways, innovation in clinical trials and, above all, patient empowerment. MASK-rhinitis (MACVIA-ARIA Sentinel NetworK for allergic rhinitis) is a simple system centred around the patient which was devised to fill many of these gaps using Information and Communications Technology (ICT) tools and a clinical decision support system (CDSS) based on the most widely used guideline in allergic rhinitis and its asthma comorbidity (ARIA 2015 revision). It is one of the implementation systems of Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). Three tools are used for the electronic monitoring of allergic diseases: a cell phone-based daily visual analogue scale (VAS) assessment of disease control, CARAT (Control of Allergic Rhinitis and Asthma Test) and e-Allergy screening (premedical system of early diagnosis of allergy and asthma based on online tools). These tools are combined with a clinical decision support system (CDSS) and are available in many languages. An e-CRF and an e-learning tool complete MASK. MASK is flexible and other tools can be added. It appears to be an advanced, global and integrated ICT answer for many unmet needs in allergic diseases which will improve policies and standards.

Integrated care pathways for airway diseases (AIRWAYS-ICPs)

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Study of methacholine positivity in patients with chronic cough at Masih Daneshvari hospital, Tehran, 2007-2008

While airways reactivity is among the characteristics of asthma, it is not considered a sufficient condition diagnostically and the methacholine challenge is a non-specific diagnostic aid in cases of chronic cough and reactive airways disease. The aim of this cross-sectional study was to determine the metacholine response positivity and diagnosis of asthma in patients with chronic cough presenting to a hospital in Tehran during 2007 and 2008. Of 101 patients with chronic cough (with no history of sinusitis, recent pulmonary infection, bronchitis, gasteroesophageal reflux or underlying pulmonary conditions), 51.5% showed reactive airways disease to the methacholine test, 40.6% were unreactive and 7.9% were indeterminate. A positive methacholine challenge test was positively correlated with new wheezing. Although the methacholine challenge test is not a primary test for evaluating chronic cough, if no other reason for chronic cough is found, it may be a guiding test for asthma.

Status and costs of smoking cessation in countries of the Eastern Mediterranean Region

The aim of this cross-sectional observational study was to address the health care situation in regard to smoking cessation efforts and expenditure, and to provide a basis for future studies and for implementing tobacco control programmes throughout the Eastern Mediterranean Region of the World Health Organization. Information collected included methods and cost of services for tobacco cessation from all 16 participating countries. In 10 countries, cessation programmes were directed by primary physicians. In 13 countries, nicotine gum and in 14 countries nicotine patches were accessible in pharmacies. Bupropion was available at pharmacies (with a written prescription) in 6 countries and varenicline in 7 countries. However, the mean cost of each service was significantly higher than the price of a pack of cigarettes. In countries with support services for tobacco cessation, directors need to provide care at the society level that is considerably less costly and widely accessible.

Drug resistance pattern and outcome of treatment in recurrent episodes of tuberculosis

Patterns of drug resistance in recurrent cases of tuberculosis may be different than in those without a history of treatment. In this retrospective study, the drug resistance pattern and outcome of treatment with DOTS category I (CAT I) regimen was compared in 63 recurrent cases and 872 new cases of pulmonary tuberculosis from April 2003 to January 2008 at the National Research Institute of Tuberculosis and Lung Disease in Tehran, Islamic Republic of Iran. Resistance to isoniazid and ethambutol was significantly more common in recurrent cases, but there were no differences in rates of resistance to rifampin, pyrazinamide, streptomycin or the rate of multi-drug resistant strains. Resistance to streptomycin was the most common. No significant differences in treatment outcome and deaths were found between the 2 groups. Due to the low frequency of multi-drug resistance in the recurrent cases, a CAT I regimen may be suitable for empirical therapy before drug sensitivity results become available.

Allergic Rhinitis and its Impact on Asthma (ARIA): achievements in 10 years and future needs

Allergic rhinitis (AR) and asthma represent global health problems for all age groups. Asthma and rhinitis frequently coexist in the same subjects. Allergic Rhinitis and its Impact on Asthma (ARIA) was initiated during a World Health Organization workshop in 1999 (published in 2001). ARIA has reclassified AR as mild/moderate-severe and intermittent/persistent. This classification closely reflects patients' needs and underlines the close relationship between rhinitis and asthma. Patients, clinicians, and other health care professionals are confronted with various treatment choices for the management of AR. This contributes to considerable variation in clinical practice, and worldwide, patients, clinicians, and other health care professionals are faced with uncertainty about the relative merits and downsides of the various treatment options. In its 2010 Revision, ARIA developed clinical practice guidelines for the management of AR and asthma comorbidities based on the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. ARIA is disseminated and implemented in more than 50 countries of the world. Ten years after the publication of the ARIA World Health Organization workshop report, it is important to make a summary of its achievements and identify the still unmet clinical, research, and implementation needs to strengthen the 2011 European Union Priority on allergy and asthma in children.

Comparison of tobacco control policies in the Eastern Mediterranean countries based on Tobacco Control Scale scores

This cross-sectional survey aimed to provide an overview of tobacco control strategies in the countries of the Eastern Mediterranean Region (EMR). A questionnaire to collate data on implementation of 6 major policies was developed based on the previously published Tobacco Control Scale and using MPOWER measures of the WHO Tobacco Free Initiative and the Tobacco Atlas. Only 3 of the 21 countries scored higher than 50 out of 100: Islamic Republic of Iran (61), Jordan (55) and Egypt (51) More than half of countries scored less than 26. Highest scores were achieved by Afghanistan in cigarette pricing, Oman in smoking bans in public places, Islamic Republic of Iran in budgeting, prohibition of advertisements and health warnings against smoking and Syrian Arab Republic, Tunisia and Kuwait in tobacco cessation programmes. The low mean total score in EMR countries (29.7) compared with European countries (47.2) highlights the need for better future planning and policy-making for tobacco control in the Region.

Quitting smoking with varenicline: parallel, randomised efficacy trial in Iran

BACKGROUND

Smoking cessation programmes were first introduced in Iran in 1997. To date a number of types of nicotine replacement therapy have been prescribed.

OBJECTIVE

To evaluate the effectiveness of varenicline for tobacco cessation.

METHODS

This was a randomised parallel clinical study conducted in 2010. Participants were smokers willing to quit who were visiting a smoking cessation clinic for the first time and were randomly divided into three groups: all three groups received brief counselling on cessation, Group 2 received nicotine patches and Group 3 was prescribed varenicline for 8 weeks.

RESULTS

There were 272 participants in the study: 91 in Group 1, 92 in Group 2 and 89 in Group 3. At the end of the first month, 128 of the 272 subjects (47.1%) succeeded in quitting: 17 (18.7%) in Group 1, 60 (65.2%) in Group 2 and 51 (57.3%) in Group 3 (P = 0.000). At follow-up after 12 months, 58 subjects (21.3%) remained smoke-free, of whom 6 (6.6%) were in Group 1, 23 (25%) in Group 2 and 29 (32.6%) in Group 3 (P = 0.000).

CONCLUSION

In the study, varenicline treatment was slightly more effective than but not significantly different from nicotine replacement therapy.

Common methods to treat addiction in treatment- rehabilitation centers in tehran

BACKGROUND

This study was to determine common methods to treat addiction used by patients checked into Outpatient Treatment and Rehabilitation Clinics in Tehran.

METHODS

The study was conducted in Social Security affiliated outpatient clinics including three governmental and several private centers in 22 districts of Tehran. Demographic data, personal information, social characteristics and information regarding prevention, treatment, and follow-up records of 1,372 patients were obtained and analyzed.

RESULTS

A majority of cases referring to the treatment centers were male (95.2%). Patients were 14 to 75 yr (mean 35.48 ± 10.57 yr); 61.7% were married and lived in rented homes in the city; 938/1372 (68.4%) had at least one previous attempt failure when seeking re-treatment. A majority of them (77.8%) had a history of 1 to 4 quit attempts; a number 63.1% had an abstinence period of 1 week to 6 months.

CONCLUSION

The majority of our understudy subjects had a history of previous attempts to treat their addiction with a maximum abstinence period of 6 months.

IL-2-inducible T-cell kinase deficiency with pulmonary manifestations due to disseminated Epstein-Barr virus infection

IL-2-inducible T-cell kinase (ITK) deficiency is a rare inherited immunodeficiency disease characterized by homozygous mutations in the ITK gene and the inability to control Epstein-Barr virus (EBV) infection leading to EBV-associated lymphoproliferative disorders of B cell origin. Many aspects of its clinical presentation and immunologic phenotype are still unclear to clinicians. We report on a 14-year-old female patient with complaints of an 8-month history of cough and fever. Imaging studies revealed diffuse pulmonary nodules and mediastinal lymphadenopathy. Transbronchial lung biopsy showed nonmalignant polyclonal B cell proliferation. High titers of EBV DNA were detected by PCR analysis in bronchoalveolar lavage fluid, bone marrow, and blood. Genomic analysis revealed a homozygous single base pair deletion in exon 5 of the ITK gene (c.468delT) in this patient. Treatment with rituximab (anti-CD20 mab) resulted in complete clinical remission with resolution of pulmonary lesions and a negative EBV titer in serum. All patients with EBV-associated lymphoproliferative disorders should be analyzed for mutations in ITK.

New Aspects in Immunopathology of Mycobacterium tuberculosis

Our understanding of tuberculosis (TB) pathology and immunology has become extensively deeper and more refined since the identification of Mycobacterium tuberculosis (MTB) as the etiologic agent of disease by Dr. Robert Koch in 1882. A great challenge in chronic disease is to understand the complexities, mechanisms, and consequences of host interactions with pathogens. TB, caused by MTB, is a major health problem in world, with 10 million new cases diagnosed each year. Innate immunity is shown playing an important role in the host defense against the MTB, and the first step in this process is recognition of MTB by cells of the innate immune system. Several classes of pattern recognition receptors (PPRs) are involved in the recognition of MTB, including toll-like receptors (TLRs), C-type lectin receptors (CLRs), and nod-like receptors (NLRs). Among the TLR family, TLR1, TLR2, TLR4, and TLR9 and their down streams, proteins play the most prominent roles in the initiation of the immune response against MTB. Beside of TLRs signaling, recently the activation of inflammasome pathway in the pathogenesis of TB much appreciated. Knowledge about these signaling pathways is crucial for understanding the pathophysiology of TB, on one hand, and for the development of novel strategies of vaccination and treatment such as immunotherapy on the other. Given the critical role of TLRs/inflammasome signaling in innate immunity and initiation of the appropriate adaptive response, the regulation of these pathways is likely to be an important determinant of the clinical outcome of MTB infection. In this review paper we focused on the immune response, which is the recognition of MTB by inflammatory innate immune cells following infection.

Inflammatory myofibroblastic tumor of the trachea

This report described a 2-year-old boy who presented with severe respiratory distress and stridor. Bronchoscopy and CT revealed a mass in the left anterolateral tracheal wall and histopathology showed a tracheal inflammatory myofibroblastic tumor. Initial removal by rigid bronchoscopy resulted in prompt recurrence of the tumor. Therefore he underwent tracheal surgical resection. A bronchoscopy at 12 months after surgery did not show any recurrence sign.

Prioritised research agenda for prevention and control of chronic respiratory diseases

The 2008-2013 World Health Organization (WHO) action plan on noncommunicable diseases (NCDs) includes chronic respiratory diseases as one of its four priorities. Major chronic respiratory diseases (CRDs) include asthma and rhinitis, chronic obstructive pulmonary disease, occupational lung diseases, sleep-disordered breathing, pulmonary hypertension, bronchiectiasis and pulmonary interstitial diseases. A billion people suffer from chronic respiratory diseases, the majority being in developing countries. CRDs have major adverse effects on the life and disability of patients. Effective intervention plans can prevent and control CRDs, thus reducing morbidity and mortality. A prioritised research agenda should encapsulate all of these considerations in the frame of the global fight against NCDs. This requires both CRD-targeted interventions and transverse NCD programmes which include CRDs, with emphasis on health promotion and disease prevention.

Eight years of lung transplantation: experience of the National Research Institute of Tuberculosis and Lung Diseases

BACKGROUND

Lung transplantation has evolved from an experimental procedure to a viable therapeutic option in many countries. In Iran, the first single-lung transplantation was performed in the year 2000, more than 3 decades after the first successful procedure in the world, and the first double-lung transplantation was performed in the year 2006.

OBJECTIVE

To describe our 8-year experience in lung transplantation.

PATIENTS AND METHODS

During 8 years, we performed 24 lung transplantation procedures. Underlying lung diseases were pulmonary fibrosis in 16 patients (66.6%); chronic obstructive pulmonary disease in 2 (8.3%); bronchiectasis in 5, including 2 patients with cystic fibrosis (20.8%), and alveolar microlithiasis in 1 (4.16%). Data for all patients were collected and analyzed. Procedures were carried out using standardized methods. The induction suppression regimen consisted of cyclosporine and methylprednisolone. Maintenance immunosuppression drugs were cyclosporine and mycophenolate mofetil, and tapering dosage of prednisolone. Patients were followed up with physical examinations, 3 times a week, as well as and cycle ergometry 3 times a week and spirometry and laboratory tests once a week and chest radiography per needed for up to 3 months posttransplantation.

RESULTS

The longest survival time was 7.2 years, in a 60-year-old patient with idiopathic pulmonary fibrosis. Fourteen patients died, 8 as a result of hemodynamic instability and/or hemorrhage, 1 as a result of bone and fat emboli, 3 after cessation of drug and 2 of them after infection.

CONCLUSION

Although lung transplantation is a complex procedure it can be performed in developing countries such as Iran.

Comparison of the effectiveness of 2 treatment regimens in patients with isoniazid-resistant tuberculosis

We compared the effectiveness of 2 treatment regimens for isoniazid-resistant tuberculosis (TB) in 42 patients attending a TB referral centre in the Islamic Republic of Iran. The patients were divided into 2 treatment groups: 26 received the 6-month standard HRZE treatment and 16 received a modified treatment of RZE for 6 months. There were no significant differences in age or sex of the groups. With the standard method of treatment, 21 (80.8%) patients were cured, 4 (15.4%) resulted in treatment failure, and 1 (3.8%) died. In the modified treatment group, 16 (100%) patients were cured, These differences were not statistically significantly different (P = 0.194).

Drug abuse profile - patient delay, diagnosis delay and drug resistance pattern - among addict patients with tuberculosis

Socioeconomic problems limit the access of drug users to health-care services. This descriptive cross-sectional study was carried out by making use of the medical records of new case tuberculosis (TB) patients hospitalized at Masih Daneshvari Hospital, the national referral centre in Iran, from 2003 to 2006. Demographic and personal characteristics of the patients and type of disease were collected and categorized. Of the 944 patients with confirmed TB, 143 (15.1%) were drug users, among whom 140 (97.9%) were men with just three women drug users. The mean age of the drug users group was 43.04 +/- 13.81 years. The type of drug used was opium in 100 cases (69.9%), heroin in 29 (20.3%), opium and heroin together in four (2.8%) and all three, opium, heroin and crack, in two (1.4%). For 238 high-risk patients, an HIV test was performed and HIV infection was confirmed in 33 cases. Patient delay was longer in drug users (P = 0.000) against other patients, whereas diagnosis delay was shorter (P = 0.007). Drug susceptibility tests were performed for 515 patients with positive cultures. One hundred and thirty-three (14.1%) were found to have 'any resistance' to anti-TB drugs, and 10 (1.1%) individuals had multidrug-resistant TB. Twenty-six (19.5%) of the individuals who showed resistance to first-line agents were drug users. There was no significant relation between drug resistance and drug use (P = 0.4). In conclusion, it seems that active case finding for TB and HIV in addict cases must be contained in harm reduction packages. Moreover, the manifestations of the disease should be considered seriously regardless of attributing them to drug use.

Role of private laboratories in tuberculosis detection in Tehran, Islamic Republic of Iran

To study the participation of the private sector in detection and diagnosis of tuberculosis, all suspected cases referring to 4 private laboratories in Tehran for acid-fast bacillus examination during 2002-03 were documented. Of 9037 cases enrolled in the study, 637 had positive examination results (7.1%). Of these 531 (5.9%) cases were direct smear-positive and 489 (5.4%) were culture-positive. Data from the Iranian Ministry of Health showed 9479 cases referred to government laboratories in Tehran urban area during the study period, 208 (2.2%) of which were positive. This larger than expected proportion of TB patients who are detected and managed by the private sector indicates that much closer cooperation is needed between the public and private sectors.

Outcome of treatment of MDR-TB patients with standardised regimens, Iran, 2002-2006

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) imposes a formidable burden on national health systems. There is still no consensus on the subject, with controversies regarding treatment protocols, treatment outcomes and the various treatment regimens.

METHODS

The present study describes Iran's second national cohort for treatment of MDR-TB. The study comprised all documented MDR-TB cases in Iran referred to our centre during the period 2002-2006. All patients received a standardised second-line regimen consisting of ofloxacin, cycloserine, prothionamide and amikacin. Based on drug susceptibility testing results, ethambutol and pyrazinamide were added to the regimen.

RESULTS

Forty-three patients diagnosed with MDR-TB, with a mean age of 44.38 +/- 19.05 years, received treatment; of these, 27 (62.8%) were male. Twenty-three were (53.5%) Iranians and the remainder were Afghans. All patients were acquired MDR-TB cases. Of the 43 cases, 25 (58.1%) experienced severe clinically significant adverse effects; 29 (67.5%) had a successful outcome and 14 (32.5%) had a poor outcome (treatment failure in six [14%] and death in eight [18.6%]). Mortality was higher in Iranians (P = 0.039) and in patients whose initial regimen was changed due to adverse drug reactions (P = 0.01).

CONCLUSION

Compared with previous studies, our study was able to obtain more favourable outcomes of MDR-TB treatment using a standardised regimen.

Prevalence of smoking among high-school students of Tehran in 2003

This study in 2003 determined the prevalence of smoking and its associated factors among high-school students in Tehran, Islamic Republic of Iran. Out of 1095 students aged 14-18 years, 29% (31% boys, 26% girls) were occasional and 5% (6% boys and 2% girls) daily smokers. Among occasional smokers, 21% had family members who also smoked, whereas for students who had never tried smoking, no family members smoked. Of 316 occasional smokers, 12% lived with a single parent compared with only 5% of never smokers. Regression analysis showed that significant risk factors for daily smoking were: having a brother or sister who smokes (OR = 8.58) and having more than 1 family member who smokes (OR = 6.33).

Clinical and laboratory profile of patients with tuberculosis/HIV coinfection at a national referral centre: a case series

This case series describes the clinical and laboratory profile of 15 patients with tuberculosis (TB) HIV coinfection admitted to a referral centre in the Islamic Republic of Iran. Most of the patients (13) were male; the mean age was 36.9 years. Intravenous drug use was the route of transmission for all males and heterosexual intercourse for the 2 females; 12 patients had a history of imprisonment. All patients had pulmonary TB; 13 were smear-positive and all except 1 had atypical radiological presentation. Drug-induced hepatitis occurred in 3 patients and 12 had hepatitis C coinfection. Five patients died. The mean CD4 count was 229.2 (SD 199.5) cells/mm3 and 78.6% had CD4 count < 350. TB may be an AIDS-defining illness in this country.

Pulmonary mycobacterium Simiae infection and HTLV1 infection: an incidental co-infection or a predisposing factor?

There is little information on atypical mycobacterium and human T lymphotropic virus Type I (HTLV-I) co-infection. We present the first case of pulmonary M. simiae infection in co-infection with HTLV-1, confirmed by ELISA antibody test and Western Blot. We discuss the clinical characteristics and laboratory tests of the patient and presumptive immunological relation. We propose that in patients with the HTLV infection and pulmonary symptoms and signs compatible with tuberculosis, evaluation for atypical mycobacteriosis may be recommendable.

Instability of IS6110 patterns in multidrug-resistant strains of Mycobacterium tuberculosis

The stability of IS6110 restriction fragment length polymorphism (RFLP) pattern was determined in 31 isolates from patients with multidrug-resistant tuberculosis (MDR-TB). These patients were in actual chains of transmission and they referred to the National Institute of Tuberculosis and Lung Diseases, Tehran, Iran. Susceptibility testing against first- and second-line drugs were performed by the proportional method on Lowenstein-Jensen culture media. Thereafter, DNA fingerprinting by IS6110 with direct repeat (DR) region as a probe was performed by standard protocols. The rate of IS6110 changes was 16%, although, no variation was found in the DR region, in a time-span of 1-63 months. The strains with unstable IS6110 patterns were resistant to all drugs tested, and the majority of them (60%) were collected from HIV-positive patients. The results demonstrated that for a reliable interpretation of strain typing, it is better to use an additional marker along with IS6110 RFLP.

Evaluation of T cell immune responses in multi-drug-resistant tuberculosis (MDR-TB) patients to Mycobacterium tuberculosis total lipid antigens

Mycobacterium tuberculosis lipid antigens produce significant T cell responses in healthy tuberculin reactor [purified protein derivative (PPD-positive] individuals. In the present study, proliferation and interferon (IFN)-gamma/interleukin (IL)-4 responses were analysed to M. tuberculosis total lipid antigens in T lymphocytes from 25 patients with multi-drug-resistant tuberculosis (MDR-TB). The obtained results were compared with those of 30 asymptomatic healthy PPD-positive and 30 healthy tuberculin skin test negative (PPD-negative) subjects. Peripheral blood mononuclear cells (PBMCs) and T cells (CD4(+) and CD8(+)) were stimulated using autologous immature dendritic cells. Proliferation responses were assessed using 3-{4,5-dimethylthiazol-2-yl}-2,5 diphenyl tetrazolium bromide (MTT). IFN-gamma/IL-4 concentrations in the supernatant of the CD4(+) and CD8(+)T cells were measured by enzyme-linked immunosorbent assay. Proliferation assay showed that the peripheral blood mononuclear cells and CD4(+) T cells from the MDR-TB patients responded significantly less to the M. tuberculosis total lipid antigens than to the CD4(+) T cells in the PPD-positive subjects. Total lipid antigen-specific proliferative responses in the CD8(+) T cells from the MDR-TB patients were minimally detected and the responses were similar to those of the PPD-positive subjects. IFN-gamma production by the CD4(+) T cells stimulated by total lipid antigens from the MDR-TB patients was decreased significantly compared with the PPD-positive individuals, whereas IL-4 production in the patients was elevated. IFN-gamma and IL-4 production in the CD8(+) T cells of the MDR-TB patients was similar to those of the PPD-positive subjects. In conclusion, it is suggested that stimulated CD4(+) T cells by M. tuberculosis total lipid antigens may be shifted to T helper 2 responses in MDR-TB patients.

Notification of patients with tuberculosis detected in the private sector, Tehran, Iran

OBJECTIVE

To determine the case notification rate of patients with tuberculosis (TB) detected by private laboratories, in Tehran, Iran.

STUDY DESIGN

Cross-sectional study.

METHOD

All confirmed TB cases among suspected cases referred to private laboratories for acid-fast bacilli (AFB) examination in 2002-2003 were enrolled in the study. All AFB-positive cases were followed up for notification to the Iranian Ministry of Health (MOH) National Tuberculosis Programme (NTP).

RESULTS

Of the total number of cases referred to private laboratories, 646 AFB-positive cases were followed up. Of these, 317 (49.1%) cases were female and 328 (50.8%) were male; the mean age was 52.2 years (SD +/- 21.7). Patients were contacted either at their residence or by telephone: 82 were found to be registered with the MOH while 564 (87.3%) could not be traced. A positive correlation was detected between physician advice for patient referral to health centres and case registration by the MOH (Fisher's Exact test 0.000).

CONCLUSION

The private sector in Tehran plays a significant role in TB detection, but there are major gaps in the collaboration between the private and public health systems.

Tuberculosis of the breast: report of 4 clinical cases and literature review

Nearly 18% of tuberculosis (TB) cases have only extrapulmonary manifestations. Breast tuberculosis is a rare type of extrapulmonary TB. This paper reports 4 cases of breast TB confirmed either pathologically or mycobacteriologically or both. These reports showed that TB should always be considered first in the differential diagnosis of granulomatous mastitis in TB-endemic areas. Therapy included at least 6 months of anti-TB medication and surgery when indicated.

Lack of association between interferon-gamma receptor-1 polymorphism and pulmonary TB in Iranian population sample

BACKGROUND

Tuberculosis is one of the most common infectious diseases in the world. In recent years, genetically approach has been developed. One of the interesting gene for investigator is IFN-gammaR1.

AIM

Determination of susceptibility to tuberculosis with polymorphism of IFN-gammaR1 gene.

MATERIAL AND METHOD

Study was prospective case-control. Fifty patients with smear positive tuberculosis have been chosen randomly. They were matched with 54 healthy controls with no history of TB. Polymorphism at 395 codon of IFN-gammaR1 gene was detected with Newport method. Data were analysed with SPSS version 11.

RESULTS

Mean age of patients and control were 55+/-20 and 53+/-13.5 years, respectively. Demographic characteristic had no difference within two groups. One patient in case group had heterozygote mutation at IFN-gammaR1 gene. In control group there were no mutations.

CONCLUSION

Genetically susceptibility to TB is not in 395 colon of IFN-gammaR1 in Iranian TB sample and polymorphism of this loci has occur in 2% of TB patients and 0.96% of total study population.

Primary multi-drug resistant tuberculosis presented as lymphadenitis in a patient without HIV infection

Primary multi-drug resistant extrapulmonary tuberculosis is an uncommon form of the disease, but it seems that by increasing the number drug resistant tuberculosis around the world, the number of cases of primary multidrug resistant tuberculosis with extrapulmonary presentation also is going to rise. In this report, we describe a 19- year old, HIV negative man with primary multi-drug resistant TB lymphadenitis, presented with cervical lymphadenopathy and sinus discharge at the site of involved lymph nodes. The Acid Fast Bacilli (AFB) smear of sputum was negative but the AFB smear of discharged fluid as well as the excisional biopsy of the lymph nodes confirmed the M. tuberculosis infection. The patient underwent the treatment with a combination of isoniazide, clofazimine, pyrazinamide, ofloxacin and amikacin with promising results. By increasing the number of drug resistant tuberculosis patients around the world, appropriate diagnosis and treatment of different presentations of the disease need a special attention.

Reasons for delay in the management of patients with pulmonary tuberculosis

The study assessed reasons for delay between patient’s first symptoms of tuberculosis and initiation of therapy. Fifty newly diagnosed cases of pulmonary tuberculosis admitted to the NRITLD in Teheran were studied. Mean patient delay before consulting a physician was 12.5 +/- 10 days, significantly higher among men than women. Mean delay until the physicians’ diagnosis was 93 +/- 80 days, significantly higher for women than for men. Almost no treatment delay was observed [mean 4 +/- 4 days after diagnosis had been confirmed]. The major delay was the time taken by physicians to diagnose tuberculosis in symptomatic patients. An active and effective national tuberculosis programme is needed in the Islamic Republic of Iran, with integration of the programme in medical school curricula and in continuing professional training.

Reasons for delay in the management of patients with pulmonary tuberculosis

The study assessed reasons for delay between patient's first symptoms of tuberculosis and initiation of therapy. Fifty newly diagnosed cases of pulmonary tuberculosis admitted to the NRITLD in Teheran were studied. Mean patient delay before consulting a physician was 12.5 +/- 10 days, significantly higher among men than women. Mean delay until the physicians' diagnosis was 93 +/- 80 days, significantly higher for women than for men. Almost no treatment delay was observed (mean 4 +/- 4 days after diagnosis had been confirmed). The major delay was the time taken by physicians to diagnose tuberculosis in symptomatic patients. An active and effective national tuberculosis programme is needed in the Islamic Republic of Iran, with integration of the programme in medical school curricula and in continuing professional training.

Improving sensitivity of direct microscopy for detection of acid-fast bacilli in sputum: use of chitin in mucus digestion

In order to try to improve the results of direct smear microscopy, we used the mucus-digesting quality of chitin in tuberculosis (TB) laboratories. For this purpose, a total of 430 sputum specimens were processed by the N-acetyl-L-cysteine concentration, sodium hypochlorite (NaOCl) liquefaction, chitin sedimentation, and direct microscopy methods. Then, the smear sensitivity for acid-fast bacillus detection by chitin-treated sputum was compared with the sensitivity of smears prepared by other methods. Our results showed that the chitin solution took less time to completely homogenize the mucoid sputum than did the N-acetyl-L-cysteine and NaOCl methods. The N-acetyl-L-cysteine concentration method demonstrated sensitivity and specificity levels of 83 and 97%, respectively. In comparison, the sensitivity of chitin sedimentation was 80%, with a specificity of 96.7%. The NaOCl liquefaction method showed a sensitivity of 78%, with a specificity of 96%. Finally, the sensitivity of direct microscopy was lower than those of the other tested methods and was only 46%, with a specificity of 90%. The chitin and NaOCl liquefaction methods are both easy to perform, and they do not require additional equipment (centrifuges). Also, our results demonstrated that the chitin method is less time-consuming than the NaOCl method, since only 30 min of incubation is required to bring complete sedimentation of bacilli in chitin-treated sputum whereas the NaOCl method needs 10 to 12 h to give the same results in the same sputum specimens. Therefore, the chitin liquefaction and sedimentation method may provide better results in TB laboratories of developing countries than the N-acetyl-L-cysteine concentration, NaOCl overnight sedimentation, and direct smear microscopy methods.

Chromosomal aberrations and micronuclei in lymphocytes of patients before and after exposure to anti-tuberculosis drugs

To evaluate the genetic damage induced by tuberculosis infection and also by a combination of therapeutic exposure to anti-tuberculosis (anti-TB) drugs (isoniazid + rifampicin + pyrazinamide + ethambutol or streptomycin) we have considered chromosome aberrations (CA) and micronuclei (MN) in binucleate peripheral blood lymphocytes from 36 patients diagnosed with pulmonary tuberculosis prior to receiving anti-TB drugs in the first phase and in the second phase after 6 months of therapy with anti-TB drugs. The same cytogenetic study has also been performed on 36 healthy individual controls. It was shown that the frequencies of both CA and micronucleated binucleate cells increased significantly after therapy with anti-TB drugs as compared with TB patients and controls. In addition, we observed that both cytogenetic markers (CA and MN) in patients before treatment with anti-TB drugs were significantly (P: < 0.05) higher than controls. No relationship was found between the frequency of MN and donor age. Thus, apart from drug effects, infection with tuberculosis is associated with increased CA and MN.

Detection of Mycobacterium tuberculosis in bronchial washing of smear-positive patients after sputum conversion

The main purpose of chemotherapy of tuberculosis is to ensure the noninfectiousness of patients with active pulmonary tuberculosis. For this reason, the sputum of smear-positive pulmonary tuberculosis patients is examined at the end of the first and second month of therapy to determine the conversion rate, which is expected to be 85% at the end of the second month. The patients whose sputum has converted to smear-negative are considered noninfectious. The aim of this study was to challenge the theory that negative sputum smear test results always indicate the absence of Mycobacterium tuberculosis bacilli in respiratory secretions from patients with active pulmonary tuberculosis after treatment. In order to achieve this goal, 46 patients with pulmonary tuberculosis whose sputum was positive for M. tuberculosis at the first visit were followed until they gave two consecutive negative smears. The bronchoalveolar lavage fluid of these patients was then examined for M. tuberculosis bacilli. It was observed that eight (17.5%) and five (10%) of these patients, who had already undergone sputum conversion, gave positive smear and culture results respectively. It could be concluded that a negative sputum result is not an appropriate index for evaluating the infectiousness of patients with pulmonary tuberculosis, and, since a few Mycobacterium tuberculosis bacilli can cause tuberculosis, especially in an immunocompromised host, it is mandatory that complementary studies to assess the transmission and virulence of Mycobacterium tuberculosis bacilli after sputum conversion be conducted.

Brain glutamate metabolism during hypoxia and peripheral chemodenervation

Glutamate stimulates resting ventilation by altering neural excitability centrally. Hypoxia increases central ventilatory drive through peripheral chemoreceptor stimulation and may also alter cerebral perfusion and glutamate metabolism locally. Therefore the effect of hypoxia and peripheral chemodenervation on cerebrospinal fluid (CSF) transfer rate of in vivo tracer amidated central nervous system glutamate was studied in intact and chemodenervated pentobarbital-anesthetized dogs during normoxia and after 1 h of hypoxia induced with 10 or 12% O2 in N2 breathing at constant expired ventilation and arterial CO2 tension. Chemodenervation was performed by bilateral sectioning of the carotid body nerves and cervical vagi. CSF transfer rates of radiotracer 13NH4+ and [13N]glutamine synthesized via the reaction, glutamate + NH4(+)----glutamine, in brain glia were measured during normoxia and after 1 h of hypoxia. At normoxia, maximal glial glutamine efflux rate jm = 103.3 +/- 11.2 (SE) mumol.l-1.min-1 in all animals. After 1 h of hypoxia in intact animals, jm = 78.4 +/- 10.0 mumol.l-1.min-1. In denervated animals, jm was decreased to 46.3 +/- 4.3 mumol.l-1.min-1. During hypoxia, mean cerebral cortical glutamate concentration was higher in denervated animals (9.98 +/- 1.43 mumol/g brain tissue) than in intact animals (7.63 +/- 1.82 mumol/g brain tissue) and corresponding medullary glutamate concentration tended to be higher in denervated animals. There were no differences between mean glutamine and gamma-aminobutyric acid concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of passive smoking on the pulmonary function of adults

The effects of exposure to environmental tobacco smoke (passive smoking) on pulmonary function of non-smoking, healthy Iranian men (n = 167) and women (n = 108) were investigated. There were significant reductions in % predicted FEV1 (5.7%), forced vital capacity (FVC, 4.6%) and forced expiratory flow 25-75% (FEF25-75, 9.9%) among men exposed to cigarette smoke (n = 78). The adverse effect of passive smoking was greatest among men exposed at the workplace (reduction in % predicted FEV1 9.4%, FVC 7.6%, and FEF25-75 15.3%). No significant difference in pulmonary function was found among the 54 women exposed to passive smoke, but only eight women had smoke exposure at work. It is concluded that exposure to environmental tobacco smoke, particularly at the workplace, adversely affects the pulmonary function of adults.