Publications by authors named "Behrooz Farzanegan"

43 Publications

No clinical benefit of high dose corticosteroid administration in patients with COVID-19: A preliminary report of a randomized clinical trial.

Eur J Pharmacol 2021 Apr 16;897:173947. Epub 2021 Feb 16.

Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Electronic address:

The aim of this study was to evaluate the clinical effects of dexamethasone administration in patients with mild to moderate acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). The study included 50 patients who were randomly assigned to the dexamethasone group or control group. Dexamethasone was administered at a dose of 20 mg/day from day 1-5 and then at 10 mg/day from day 6-10. The need for invasive mechanical ventilation, death rate, duration of clinical improvement, length of hospital stay, and radiological changes in the computed tomography scan were assessed. The results revealed that 92% and 96% of patients in the dexamethasone and control groups, respectively, required noninvasive ventilation (P = 0.500). Among them, 52% and 44% of patients in the dexamethasone and control groups, respectively, required invasive mechanical ventilation (P = 0.389). At the end of the study, 64% of patients in the dexamethasone group and 60% of patients in the control group died (P = 0.500); the remaining patients were discharged from the hospital during the 28-day follow-up period. The median length of hospital stay was 11 days in the dexamethasone group and 6 days in the control group (P = 0.036) and the median length of hospital stay was 7 days in the dexamethasone group and 3 days in the control group (P < 0.001). No significant differences were observed in the other outcomes. This study showed that corticosteroid administration had no clinical benefit in patients with COVID-19-induced mild to moderate ARDS.
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http://dx.doi.org/10.1016/j.ejphar.2021.173947DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885705PMC
April 2021

Evaluation of the efficacy and safety of inhaled magnesium sulphate in combination with standard treatment in patients with moderate or severe COVID-19: A structured summary of a study protocol for a randomised controlled trial.

Trials 2021 Jan 18;22(1):60. Epub 2021 Jan 18.

Tracheal Diseases Research Centre, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Objectives: Basic and clinical studies have shown that magnesium sulphate ameliorates lung injury and controls asthma attacks by anti-inflammatory and bronchodilatory effects. Both intravenous and inhaled magnesium sulphate have a clinical impact on acute severe asthma by inhibition of airway smooth muscle contraction. Besides, magnesium sulphate can dilate constricted pulmonary arteries and reduce pulmonary artery resistance. However, it may affect systemic arteries when administered intravenously. A large number of patients with covid-19 admitted to the hospital suffer from pulmonary involvement. COVID-19 can cause hypoxia due to the involvement of the respiratory airways and parenchyma along with circulatory impairment, which induce ventilation-perfusion mismatch. This condition may result in hypoxemia and low arterial blood oxygen pressure and saturation presented with some degree of dyspnoea and shortness of breath. Inhaled magnesium sulphate as a smooth muscle relaxant (natural calcium antagonist) can cause both bronchodilator and consequently vasodilator effects (via a direct effect on alveolar arterioles in well-ventilated areas) in the respiratory tract. We aim to investigate if inhaled magnesium sulphate as adjuvant therapy to standard treatment can reduce ventilation-perfusion mismatch in the respiratory tract and subsequently improve arterial oxygen saturation in hospitalized patients with COVID-19.

Trial Design: A multi-centre, open-label, randomised controlled trial (RCT) with two parallel arms design (1:1 ratio) PARTICIPANTS: Patients aged 18-80 years hospitalized at Masih Daneshvari Hospital and Shahid Dr. Labbafinejad hospital in Tehran and Shahid Sadoughi Hospital in Yazd will be included if they meet the inclusion criteria of the study. Inclusion criteria are defined as 1. Confirmed diagnosis of SARS-CoV-2 infection based on polymerase chain reaction (PCR) of nasopharyngeal secretions or clinical manifestations along with chest computed tomography (chest CT) scan 2. Presenting with moderate or severe COVID-19 lung involvement confirmed with chest CT scan and arterial oxygen saturation below 93% 3. Length of hospital stay ≤48 hours. Patients with underlying cardiovascular diseases including congestive heart failure, bradyarrhythmia, heart block, the myocardial injury will be excluded from the study.

Intervention And Comparator: Participants will be randomly divided into two arms. Patients in the intervention arm will be given both standard treatment for COVID-19 (according to the national guideline) and magnesium sulphate (5 cc of a 20% injectable vial or 2 cc of a 50% injectable vial will be diluted by 50 cc distilled water and nebulized via a mask) every eight hours for five days. Patients in the control (comparator) arm will only receive standard treatment for COVID-19.

Main Outcomes: Improvement of respiratory function and symptoms including arterial blood oxygen saturation, dyspnoea (according to NYHA functional classification), and cough within the first five days of randomization.

Randomisation: Block randomisation will be used to allocate eligible patients to the study arms (in a 1:1 ratio). Computer software will be applied to randomly select the blocks.

Blinding (masking): The study is an open-label RCT without blinding.

Numbers To Be Randomised (sample Size): The trial will be performed on 100 patients who will be randomly divided into two arms of control (50) and intervention (50).

Trial Status: The protocol is Version 5.0, January 05, 2021. Recruitment of the participants started on July 30, 2020, and it is anticipated to be completed by February 28, 2021.

Trial Registration: The trial was registered in the Iranian Registry of Clinical Trials (IRCT) on July 28, 2020. It is available on https://en.irct.ir/trial/49879 . The registration number is IRCT20191211045691N1.

Full Protocol: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting the dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.
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http://dx.doi.org/10.1186/s13063-021-05032-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7812339PMC
January 2021

Clinical Manifestations of Patients with Coronavirus Disease 2019 (COVID-19) in a Referral Center in Iran.

Tanaffos 2020 Nov;19(2):122-128

Clinical Tuberculosis and Epidemiology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Following the recent epidemic of coronavirus disease 2019 (COVID-19) in Wuhan, China, a novel betacoronavirus was isolated from two patients in Iran on February 19, 2020. In this study, we aimed to determine the clinical manifestations and outcomes of the first confirmed cases of COVID-19 infection (n=127).

Materials And Methods: This prospective study was conducted on all COVID-19-suspected cases, admitted to Masih Daneshvari Hospital (a designated hospital for COVID-19), Tehran, Iran, since February 19, 2020. All patients were tested for COVID-19, using reverse transcription-polymerase chain reaction (RT-PCR) assay. Data of confirmed cases, including demographic characteristics, clinical features, and outcomes, were collected and compared between three groups of patients, requiring different types of admission (requiring ICU admission, admission to the general ward, and transfer to ICU).

Results: Of 412 suspected cases, with the mean age of 54.1 years (SD=13.4), 127 (31%) were positive for COVID-19. Following the patients' first visit to the clinic, 115 cases were admitted to the general ward, while ten patients required ICU admission. Due to clinical deterioration in the condition of 25 patients (out of 115 patients), ICU admission was essential. Based on the results, the baseline characteristics of the groups were similar. Patients requiring ICU admission were more likely to have multiorgan involvement (liver involvement, P<0.001; renal involvement, P<0.001; and cardiac involvement, P=0.02), low O saturation (P<0.001), and lymphopenia (P=0.05). During hospital admission, 21 (16.5%) patients died, while the rest (83.5%) were discharged and followed-up until March 26, 2020. Also, the survival rate of patients, who received immunoglobulin, was higher than other patients (60.87% vs. 39.13%).

Conclusion: The mortality rate of COVID-19 patients was considerable in our study. Based on the present results, this infection can cause multiorgan damage. Therefore, intensive monitoring of these patients needs to be considered.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680520PMC
November 2020

COVID-19 in Iran: A model for Crisis Management and Current Experience.

Iran J Pharm Res 2020 ;19(2):1-8

Department of Medical-Surgical Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

In February 2020, the first sample test was confirmed as positive for corona virus in Masih Daneshvari Hospital that is the reference center in Iran for all pulmonary and respiratory diseases. The decisions made in a hospital or organization to manage a crisis is very vital. Success in managing any crisis requires a scientific and scholarly attitude. This paper was distilled from experiences gained in Masih Daneshvari Hospital in Tehran, capital of Iran, in March 2020 at the stubborn time of coping and managing corona virus crisis. This study was conducted using participatory action research, a methodology which identifies problems in practice, and finds methods to solve them. This Action research involves five stages: statement of the problem, planning, data interpretation and analysis, action, and evaluation of the research process during performing the study. The whole hospital was equipped for corona virus patients in 10 phases during one week and 250 active beds were equipped for these patients. Three models, namely, "corona virus crisis management model", "Pharmaceutical care management in coronavirus crisis model" and "nursing in coronavirus crisis model" were planned and implemented. During one month of implementing these three models, the supervision team monitored the accurate implementation of instructions and resolving or revising the possible deficiencies and faults. The Masih Daneshvari crisis management model in coronavirus, can be a useful and applicable model in other corona virus centers.
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http://dx.doi.org/10.22037/ijpr.2020.113365.14255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7667532PMC
January 2020

Diffuse alveolar damage and thrombotic microangiopathy are the main histopathological findings in lung tissue biopsy samples of COVID-19 patients.

Pathol Res Pract 2020 Oct 19;216(10):153228. Epub 2020 Sep 19.

Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Since the outbreak of the novel coronavirus disease-2019 (COVID-19) in December 2019, limited studies have investigated the histopathologic findings of patients infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).

Material And Methods: This study was conducted on 31 deceased patients who were hospitalized for COVID-19 in a tertiary hospital in Tehran, Iran. A total of 52 postmortem tissue biopsy samples were obtained from the lungs and liver of decedents. Clinical characteristics, laboratory data, and microscopic features were evaluated. Reverse transcription polymerase chain reaction (RT-PCR) assay for SARS-CoV-2 was performed on specimens obtained from nasopharyngeal swabs and tissue biopsies.

Results: The median age of deceased patients was 66 years (range, 30-87 years) and 25 decedents (81 %) were male. The average interval from symptom onset to death was 13 days (range, 6-34 days). On histopathologic examination of the lung specimens, diffuse alveolar damage and thrombotic microangiopathy were the most common findings (80 % and 60 %, respectively). Liver specimens mainly showed macrovesicular steatosis, portal lymphoplasmacytic inflammation and passive congestion. No definitive viral inclusions were observed in any of the specimens. In addition, 92 % of lung tissue samples tested positive for SARS-CoV-2 by RT-PCR.

Conclusions: Further studies are needed to investigate whether SARS-CoV-2 causes direct cytopathic changes in various organs of the human body.
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http://dx.doi.org/10.1016/j.prp.2020.153228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837112PMC
October 2020

Stress and burnout in health care workers during COVID-19 pandemic: validation of a questionnaire.

Z Gesundh Wiss 2020 Jun 6:1-6. Epub 2020 Jun 6.

Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Aim: To validate a questionnaire to assess stress and burnout in healthcare workers during COVID-19 pandemic.

Subjects And Methods: In this study, content validity, Cronbach's alpha, and test-retest reliability method were utilized among 60 HCWs to evaluate the validity, internal consistency, and reliability of the questionnaire respectively. The final questionnaire was composed of four parts asking for the background information, questions about the stress caused by the COVID-19, the Depression, Anxiety and Stress Scale - 21 (DASS-21), and six questions from the Copenhagen Burnout Inventory (CBI).

Results: The CVR of 46 questions was equal to 1, making them acceptably valid (CVR > 0.78), so that the items could be arranged into a final questionnaire. Moreover, all items could successfully attain CVI values above 0.79, confirming the content validity of the questionnaire. The Cronbach's alpha was between 0.80-0.95 for different sections of questionaire, confirming the stable reliability and high repeatability of the questionnaire.

Conclusion: The results of this study showed that the DASS-21 offers adequate levels of validity and reliability for assessing the stress, anxiety, and depression among the HCWs engaged with the COVID-19 pandemic. Moreover, the six items adapted from the Copenhagen burnout inventory (CBI) were found to provide a good instrument for investigating the job burnout among the HCWs at Masih Daneshvari Hospital during the outbreak of the COVID-19 epidemic.
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http://dx.doi.org/10.1007/s10389-020-01313-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275852PMC
June 2020

Extracorporeal membrane oxygenation and COVID-19: The causes of failure.

J Card Surg 2020 Oct 17;35(10):2838-2843. Epub 2020 Jul 17.

Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Introduction: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a therapeutic strategy for the coronavirus disease 2019 (COVID-19) induced acute respiratory distress syndrome (ARDS). There are inconclusive data in this regard and causes of VV-ECMO failure are not yet understood well.

Case Series: Here, seven patients with COVID-19-induced ARDS who underwent VV-ECMO introduced and causes of VV-ECMO failure discussed. Medical records of seven COVID-19 patients treated with VV-ECMO were retrospectively evaluated to determine the clinical outcomes of VV-ECMO. Oxygenator failure occurred in four patients whom needed to oxygenator replacement. Successful VV-ECMO decannulation was done in three patients, however finally one patient survived.

Conclusions: Hypercoagulability state and oxygenator failure were the most main etiologies for VV-ECMO failure in our study. All patients with COVID-19 undergoing VV-ECMO should be monitored for such problems and highly specialized healthcare team should monitor the patients during VV-ECMO.
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http://dx.doi.org/10.1111/jocs.14867DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7404852PMC
October 2020

An Observational Study of QTc Prolongation in Critically Ill Patients: Identification of Incidence and Predictors.

Indian J Crit Care Med 2020 Apr;24(4):270-275

Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.

Aims: Despite the importance of abnormal QTc interval values in intensive care unit (ICU) patients, there is a paucity of information on this topic. The current study was designed to identify the incidence and predictors of QTc prolongation in medical (M), surgical (S), and emergency (E) ICUs.

Materials And Methods: A prospective observational study was conducted for 6 months. Patients more than 18 years old who admitted to MICU, SICU, and EICU were included in the study. Electrocardiogram (ECG) was taken on day 1, 3, and 5 of ICU admission. The QTc intervals >460 ms in male and >470 ms in female and increased >60 ms above baseline were considered QTc prolongation. Comparative analysis was done between two groups of patients (normal vs prolonged QTc). Logistic regression models were carried out to determine the predictors of QTc prolongation.

Results: Incidence of QTc prolongation was 6.5, 9.8, and 15.7% on day 1, 3, and 5 of ICU admission, respectively. On day 1, the history of alcohol addiction and the reason of ICU admission were associated with a prolonged QTc. A significant association was demonstrated between administration of azithromycin and QTc prolongation on day 3. High serum creatinine and hospitalization in EICU were predictors of QTc prolongation on day 5 of ICU admission.

Conclusion: The QTc prolongation is relatively common among patients admitted to ICUs and its incidence increases with increasing length of hospital stay. Predictors of QTc prolongation may be affected by the duration of ICU admission. Physicians should consider these predictors particularly before prescribing QTc-prolonging drugs.

How To Cite This Article: Farzanegan B, Hosseinpoor Z, Baniasadi S, Seyyedi SR, Rajabi M. An Observational Study of QTc Prolongation in Critically Ill Patients: Identification of Incidence and Predictors. Indian J Crit Care Med 2020;24(4):270-275.
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http://dx.doi.org/10.5005/jp-journals-10071-23411DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7297246PMC
April 2020

Drug interactions and creatinine levels are associated with QTc prolongation in intensive care units: a prospective, observational study.

Drug Metab Pers Ther 2019 12;34(4)

Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background Prolongation of the QTc interval may lead to life threatening arrhythmias. QTc prolongation is common in intensive care unit (ICU) patients. The objectives of this study were to identify the role of drug-drug interactions (DDIs) and other predictors (age, sex, cardiovascular diseases, and electrolyte abnormalities) in life threatening QTc prolongation in patients admitted to medical (M), surgical (S) and emergency (E) ICUs. Methods This prospective, observational study included patients above the age of 18 years who were admitted to SICU, EICU, and MICU at a tertiary respiratory referral center. Electrocardiogram (ECG) monitoring was performed during the first 5 days of ICU admission. Risk factors and DDIs which were anticipated to be associated with the prolongation of the QTc interval were assessed for all patients. Results Two hundred patients were included in the study. QTc prolongation occurred in 10.7% of patients and the majority of patients presenting with QTc prolongation had creatinine levels above 1.3 mg/dL during their 5 days of ICU admission. Incidence of pharmacodynamic (PD) DDIs was significantly higher in patients with QTc prolongation vs. other patients. Creatinine levels above 1.3 mg/dL and PD DDIs were associated with QTc prolongation during 5 days of ICU admission. Conclusions High serum creatinine and PD DDIs can increase the risk of QTc prolongation in patients admitted to the ICU. QTc interval measurements should be performed prior to initiation or after starting any drug that is associated with QT prolongation, specifically in patients with the known risk factors.
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http://dx.doi.org/10.1515/dmpt-2019-0022DOI Listing
December 2019

Impact of Religiosity on Delirium Severity Among Critically Ill Shi'a Muslims: A Prospective Multi-Center Observational Study.

J Relig Health 2021 Apr;60(2):816-840

Department of Emergency Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, 600 Moye Blvd, Greenville, NC, 27834, USA.

This study assesses the impact of religiosity on delirium severity and patient outcomes among Shi'a Muslim intensive care unit (ICU) patients. We conducted a prospective observational cohort study in 21 ICUs from 6 Iranian academic medical centers. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU) tool. Eligible patients were intubated, receiving mechanical ventilation (MV) for ≥ 48 h. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. A total of 4200 patients were enrolled. Patient religiosity was categorized as more (40.6%), moderate (42.3%), or less (17.1%) based on responses to patient and surrogate questionnaires. The findings suggest that lower pre-illness religiosity may be associated with greater delirium severity, MV duration, and ICU and hospital LOS. The lower mortality in the less religiosity group may be related in part to a greater proportion of female patients, but it remains unclear whether and to what extent greater religiosity impacted treatment decisions by patients and families. Further investigation is needed to validate and clarify the mechanism of the mortality findings.
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http://dx.doi.org/10.1007/s10943-019-00895-7DOI Listing
April 2021

A rapid shallow breathing index threshold of 85 best predicts extubation success in chronic obstructive pulmonary disease patients with hypercapnic respiratory failure.

J Thorac Dis 2019 Apr;11(4):1223-1232

Department of Emergency Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, Greenville, NC, USA.

Background: The rapid shallow breathing index (RSBI) is used clinically to help predict a patient's likelihood of successful liberation from mechanical ventilation (MV). However, the traditional threshold (<105 breaths/min/L) may underperform in patients with chronic obstructive pulmonary disease (COPD). We sought to determine the optimal RSBI threshold for COPD patients to improve the diagnostic accuracy for predicting successful ventilator liberation.

Methods: This was a prospective observational multicenter study of COPD patients [according to Global initiative for Chronic Obstructive Lung Disease (GOLD) criteria] admitted to the Medical ICUs of eight academic medical centers. All patients were intubated for hypercapnic respiratory failure and met the American Thoracic Society/European Respiratory Society guidelines to participate in a weaning trial. Ventilator weaning was conducted according to a defined protocol. RSBI was measured through the ventilator after 120 minutes of spontaneous breathing trial (SBT).

Results: Ninety patients were included (39 males and 51 females). Forty-three patients (48%) were successfully extubated whereas 47 patients (52%) failed extubation. Significant differences were observed between groups for duration-of-intubation [duration of intubation (DoI); P<0.0001], spontaneous tidal volume (VT) (P=0.03), and the ratio of dynamic-to-static compliance (P=0.005). The RSBI threshold of ≤85 breaths/min/L performed best: area under curve (AUC) receiver operating characteristic (ROC) curves 0.91, sensitivity 95.6%, specificity 90.4%, positive predictive value (PPV) 95.5%, and negative predictive value (NPV) 90.6%., positive likelihood ratio (LR+) 5.48, negative likelihood ratio (LR-) 0.25, and the diagnostic accuracy 91.7%. In post-ROC analyses, DoI and hospital length-of-stay (LOS) did not impact performance.

Conclusions: In COPD patients intubated with hypercapnia, RSBI ≤85 breaths/min/L outperformed the widely used threshold <105 breaths/min/L, yielding a 95.5% probability of extubation success, independent of ventilation duration or hospital LOS.
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http://dx.doi.org/10.21037/jtd.2019.03.103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6531712PMC
April 2019

First Experience with Extracorporeal Membrane Oxygenation in Iran, under Difficult Conditions.

J Tehran Heart Cent 2018 Oct;13(4):166-172

Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Extracorporeal membrane oxygenation (ECMO) provides hemodynamic and oxygenation support in critical conditions. The commencement of this modality in Iran coincided with severe economic constraints across Iran. This retrospective study was performed in Masih Daneshvari Medical Center from 2010 to 2015, during which period, sanction-related limitations in the import of equipment prompted us to integrate a Medtronic or Stöckert head pump console into a Maquet ECMO Oxygenator so as to sustain the ECMO program. Comparisons were performed between successful and unsuccessful ECMO procedures and survivors. Factors associated with unsuccessful ECMO were evaluated with a multivariate logistic regression. Thirty-three (68.8%) patients were male and 15 (31.2%) were female. The mean age of the patients was 35±16.6 years. Thirty-seven (77.1%) patients were weaned off ECMO successfully; the rate was higher than that in previous studies. Totally, 35.4% of the study population survived to hospital discharge. The most common cause of death in all the ECMO patients who were successfully weaned was sepsis. The most common cause of death in the patients who underwent unsuccessful ECMO was multisystem organ failure. The mean ECMO support time was 53.37±46.26 hours. The patients who were alive at discharge were significantly younger (25.5±14.5 vs. 40.2±15.5 y; P=0.002) and had a significantly lower ECMO duration (24 [25-75% interquartile: 18.5-36] vs. 48 [25-75% interquartile: 24-72] h; P=0.044) than the non-survivors. An assembly of ECMO components from different companies could be done safely, at least for a short period of time.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6450813PMC
October 2018

Effect of Nebulized Verapamil on Oxygenation in Chronic Obstructive Pulmonary Disease (COPD) Patients Admitted to the Intensive Care Unit.

Tanaffos 2019 Apr;18(4):329-337

Critical Care Quality Improvement Research Center, Shahid Modarres Hospital, Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Many pharmacological and behavioral therapies have been investigated to improve oxygenation in the intensive care unit (ICU). In patients with chronic obstructive pulmonary disease (COPD), the purpose of therapy is to correct the ventilation perfusion (V/Q) mismatch. Agents, such as calcium blockers, can affect both ventilation and vasculature. The inhalation route allows a more rapid achievement of therapeutic effects with few systemic side effects. Therefore, the present study aimed to investigate the effect of nebulized verapamil on oxygenation in COPD patients.

Materials And Methods: In this double-blind, randomized clinical trial, twenty hypoxic COPD patients, admitted to ICU, were treated with 10 mg of verapamil twice daily for three days. Also, twenty patients with COPD, who were matched in terms of age, sex, and severity of the disease, were enrolled in the control group and received nebulized normal saline. The oxygenation parameters were compared using an arterial blood gas (ABG) test before and after the intervention.

Results: The mean oxygen saturation was 91.2%±12.15 before verapamil inhalation, which increased to 95.75%±14.57 after receiving nebulized verapamil (P<0.05). Also, correction of blood pH, blood oxygen pressure, and oxygen ratio (PaO/FIO) were higher in patients receiving verapamil, compared to the control group. The length of hospital stay was similar in the two groups. During the first three days, 30% of patients in the verapamil group and 20% of patients in the control group were intubated.

Conclusion: Our results indicated that verapamil inhalation increased oxygen saturation and accelerated extubation in patients with COPD.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7309890PMC
April 2019

Study Protocol on Antimicrobial Stewardship in a Tertiary Respiratory Referral Hospital.

Tanaffos 2018 Mar;17(3):183-187

Clinical Tuberculosis and Epidemiology Research Center, NIRTLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Antimicrobial stewardship program is a comprehensive, longitudinal program designed to improve and measure the appropriateness of antimicrobial use while increasing patients' safety, decreasing cost of patients' care, and combating emerging antimicrobial resistance. Antimicrobial resistance, specially emerging multidrug-resistance and extremely drug-resistance gram negative bacteria, is an important concern in the modern world. This is particularly problematic since antimicrobials in production pipelines are not meeting the demand for the emerging resistance micro-organisms; in another word "we are running out of options". Indiscriminate use of antimicrobial may increase the risk for resistance, and drug toxicity. The aim of this study is to implement an evidence-based antimicrobial stewardship program in a tertiary referral hospital. This study will assure consistency of the stewardship program and measure outcomes to further assess the effectiveness of this program.

Materials And Methods: After establishment of antimicrobial stewardship committee and endorsement of policies the program will be conducted in all hospital medical wards. In an observational study, all patients receiving antimicrobials included in the program will be closely monitored for primary and secondary outcomes. Hospital's antimicrobial resistance patterns are monitored periodically to assess improvement. The quality indicators will be assessed to ensure proper execution of the program over time.

Results: As a study protocol, there are no results available to be reported at this time.

Conclusion: We are expecting to observe significant reduction in cost of antibiotic use shortly after program execution. By more appropriate utilization of antibiotics patients' safety will be increased. Furthermore, we are expecting to detect improvement in antimicrobial resistance patterns.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6428375PMC
March 2018

Evaluation of cerebral oxygen saturation during hypotensive anesthesia in functional endoscopic sinus surgery.

J Anaesthesiol Clin Pharmacol 2018 Oct-Dec;34(4):503-506

Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background And Aims: Controlled hypotensive anesthesia in endoscopic sinus surgery would provide a clean surgical field. Cerebral oxygen saturation (ScO) is important in endoscopic sinus surgery patients and it may be low during controlled hypotension. The aim of the present study was to assess ScO in these patients.

Material And Methods: In this observational study, 41 patients who underwent endoscopic sinus surgery with hypotensive anesthesia were enrolled for the study and all of the patients received the same anesthetic medication, nitroglycerin for controlled hypotension. Variables were measured prior to surgery, after induction of anesthesia, 5 min, and every 30 min after controlled hypotension. Near-infrared spectroscopy was used for ScO evaluation. Mean arterial blood pressure (MAP) was maintained at 55-60 mmHg in the surgical duration. We used -test, Wilcoxon, and repeated measures analysis of variance (ANOVA). We examined the cross-correlation functions of the time series data between end-tidal carbon dioxide (ETCO)/MAP and ScO.

Results: The mean of intraoperative ScO was not significantly different from the baseline evaluation ( > 0.05). ETCO was cross correlated with current ScO [: 0.618, confidence interval (CI) 95%: 0.46-0.78]. We found moderate cross correlation between the MAP and current ScO (: 0.728, CI 95%: 0.56-0.88). About 92% of the patients recovered within 30 min. Recovery time was associated with intraoperative MAP (: 0.004, : 0.438), intraoperative ETCO (: 0.003, : 0.450), and ScO (: 0.026, : 0.348).

Conclusions: Based on our findings, the assessment of ScO and maintained MAP >55 mmHg may provide safe conditions for endoscopic sinus surgery.
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http://dx.doi.org/10.4103/joacp.JOACP_248_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360878PMC
February 2019

Enterovirus-Human Rhinovirus as a Leading Cause of ARDS in a Liver Transplant Recipient.

Tanaffos 2019 Feb;18(2):169-172

Clinical Tuberculosis and Epidemiology Research Center, NRITLD, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

A 35- year- old man with a prior history of liver transplantation 18 months ago was admitted to our Intensive Care Unit (ICU) with fever and worsening dyspnea and was diagnosed with severe pneumonia leading to Acute Respiratory Distress Syndrome (ARDS). He had a prolonged hospitalization and was treated with empiric broad spectrum intravenous antibiotics, oseltamivir, trimethoprim/sulfamethoxazole, and subsequently caspofungin and ganciclovir. Blood, nasopharyngeal, as well as Bronchoalveolar Lavage (BAL) culture and Polymerase Chain Reaction (PCR) were negative for all viral, bacterial, and fungal causes of pulmonary infection except Enterovirus-Human Rhinovirus (EV-HRV) that was positive with high titers on BAL and swab specimens. Consequently, the diagnosis of EV-HRV pneumonia complicated by ARDS was established. The patient gradually improved and was discharged from the hospital after 3 weeks. This report highlights EV-HRV as a cause of ARDS in immunocompromised adults.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230127PMC
February 2019

Real-time compression feedback for patients with in-hospital cardiac arrest: a multi-center randomized controlled clinical trial.

J Intensive Care 2019 22;7. Epub 2019 Jan 22.

11Department of Emergency Medicine, Vident Medical Center, East Carolina University Brody School of Medicine, 600 Moye Blvd, Greenville, NC 27834 USA.

Objective: To determine if real-time compression feedback using a non-automated hand-held device improves patient outcomes from in-hospital cardiac arrest (IHCA).

Methods: We conducted a prospective, randomized, controlled, parallel study (no crossover) of patients with IHCA in the mixed medical-surgical intensive care units (ICUs) of eight academic hospitals. Patients received either standard manual chest compressions or compressions performed with real-time feedback using the Cardio First Angel™ (CFA) device. The primary outcome was sustained return of spontaneous circulation (ROSC), and secondary outcomes were survival to ICU and hospital discharge.

Results: One thousand four hundred fifty-four subjects were randomized; 900 were included. Sustained ROSC was significantly improved in the CFA group (66.7% vs. 42.4%,  < 0.001), as was survival to ICU discharge (59.8% vs. 33.6%) and survival to hospital discharge (54% vs. 28.4%,  < 0.001). Outcomes were not affected by intra-group comparisons based on intubation status. ROSC, survival to ICU, and hospital discharge were noted to be improved in inter-group comparisons of non-intubated patients, but not intubated ones.

Conclusion: Use of the CFA compression feedback device improved event survival and survival to ICU and hospital discharge.

Trial Registration: The study was registered with Clinicaltrials.gov (NCT02845011), registered retrospectively on July 21, 2016.
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http://dx.doi.org/10.1186/s40560-019-0357-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6341760PMC
January 2019

Comparison of non-invasive to invasive oxygenation ratios for diagnosing acute respiratory distress syndrome following coronary artery bypass graft surgery: a prospective derivation-validation cohort study.

J Cardiothorac Surg 2018 Nov 27;13(1):123. Epub 2018 Nov 27.

Department of Emergency Medicine, Vident Medical Center, East Carolina University Brody School of Medicine, 600 Moye Blvd, Greenville, NC, 27834, USA.

Objective: To determine if non-invasive oxygenation indices, namely peripheral capillary oxygen saturation (SO)/fraction of inspired oxygen (FO) and partial pressure of alveolar oxygen (PO)/FO may be used as effective surrogates for the partial pressure of arterial oxygen (PO)/FO. Also, to determine the SO/FO and PO/FO values that correspond to PO/FO thresholds for identifying acute respiratory distress syndrome (ARDS) in patients following coronary artery bypass graft (CABG) surgery.

Methods: A prospective derivation-validation cohort study in the Open-Heart ICU of an academic teaching hospital. Recorded variables included patient demographics, ventilator settings, chest radiograph results, and SO, PO, PO SO, and FO. Linear regression modeling was used to quantify the relationship between indices. Receiver operating characteristic (ROC) curves were used to determine the sensitivity and specificity of the threshold values.

Results: One-hundred seventy-five patients were enrolled in the derivation cohort, and 358 in the validation cohort. The SO/FO and PO/FO ratios could be predicted well from PO/FO, described by the linear regression models SO/FO = 71.149 + 0.8PF and PO/FO = 38.098 + 2.312PF, respectively. According to the linear regression equation, a PO/FO ratio of 300 equaled an SO/FO ratio of 311 (R 0.857, F 1035.742, < 0.0001) and a PO/FO ratio of 732 (R 0.576, F 234.887, < 0.0001). The SO/FO threshold of 311 had 90% sensitivity, 80% specificity, LR+ 4.50, LR- 0.13, PPV 98, and NPV 42.1 for the diagnosis of mild ARDS. The PO/FO threshold of 732 had 86% sensitivity, 90% specificity, LR+ 8.45, LR- 0.16, PPV 98.9, and NPV 36 for the diagnosis of mild ARDS. SO/FO had excellent discrimination ability for mild ARDS (AUC ± SE = 0.92 ± 0.017; 95% CI 0.889 to 0.947) as did PO/FO (AUC ± SE = 0.915 ± 0.018; 95% CI 0.881 to0.942).

Conclusions: PO and SO correlated in the diagnosis of ARDS, with a PO/FO of 300 correlating to an SO/ FO of 311 (Sensitivity 90%, Specificity 80%). The SO/ FO ratio may allow for early real-time rapid identification of ARDS, while decreasing the cost, phlebotomy, blood loss, pain, skin breaks, and vascular punctures associated with serial arterial blood gas measurements.
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http://dx.doi.org/10.1186/s13019-018-0804-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260696PMC
November 2018

ECMO-assisted resection of huge thoracic mass.

J Cardiovasc Thorac Res 2018 21;10(3):174-176. Epub 2018 May 21.

Lung Transplantation Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Some advanced thoracic malignancy cannot be resected safely by using of conventional ventilation, so some sort of cardiopulmonary support is needed for hemodynamic and ventilation management of the patient. Using extracorporeal membrane oxygenation (ECMO) in comparing with cardiopulmonary bypass has some advantages. Three patients with huge thoracic tumors with different ages experienced major surgery in our center by using ECMO in order to face major complications mainly due to the size of mass to achieve better hemostatic stabilities, lower bleeding, and injuries to main airways and secure oxygenation. This is the first case series in Iran, as our best knowledge that explains cases of huge chest mass which were operated perfectly by using ECMO and short ICU stay and interestingly no major complications.
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http://dx.doi.org/10.15171/jcvtr.2018.28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6203866PMC
May 2018

High-Frequency Jet Ventilation in Nonintubated Patients.

Turk Thorac J 2018 Jul 1;19(3):127-131. Epub 2018 Jul 1.

Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Objectives: High-frequency jet ventilation (HFJV) is a convenient method for providing ventilation during fiberoptic bronchoscopy. We describe an incipient approach of high-frequency jet ventilation via the working channel of a flexible bronchoscope for nonintubated patients who suffer from hypoxemia during bronchoscopy. The aim of this study was to test the efficacy of this incipient approach and determine the possible complications related to it.

Materials And Methods: Sixteen patients who had oxygen saturation below 70% that did not resolve with nasal oxygen for 20 s during interventional bronchoscopy were included in the study. High-frequency jet ventilation was administrated via the working channel of a bronchoscope for 3 min. Arterial blood gas circumscriptions were compared before and after jet ventilation.

Results: Oxygen saturation increased to >90% in all patients 30 s after jet ventilation. Mean arterial oxygen saturation pressure increased from 54.84 to 111.98 mmHg with jet ventilation (p=0.0001). Arterial carbon dioxide tension decreased after jet ventilation. The body mass index had no consequential effect on arterial carbon dioxide pressure after jet ventilation in our patients (p=0.1). Complications such as pneumothorax and working channel damage were not observed.

Conclusion: High-frequency jet ventilation via the working channel of the bronchoscope is a novel method that can provide optimal ventilation with minimal complications to nonintubated patients suffering from hypoxemia during bronchoscopy. This method also reduces the duration of bronchoscopy procedures.
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http://dx.doi.org/10.5152/TurkThoracJ.2018.17025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077008PMC
July 2018

Effect of Adding Magnesium Sulphate to Epidural Bupivacaine and Morphine on Post-Thoracotomy Pain Management: A Randomized, Double-Blind, Clinical Trial.

Basic Clin Pharmacol Toxicol 2018 Nov 9;123(5):602-606. Epub 2018 Jul 9.

Tracheal Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Post-thoracotomy pain is very severe and may cause pulmonary complications. Thoracic epidural analgesia can greatly decrease the pain experience and its consequences. However, finding new methods to decrease the amount of administered opioids is an important issue of research. We aimed to evaluate the effect of adding epidural magnesium sulphate to bupivacaine and morphine on pain control and the amount of opioid consumption after thoracotomy. Eighty patients undergoing thoracotomy at a tertiary cardiothoracic referral centre were enrolled in a randomized, double-blind trial. Patients were randomly allocated to two groups. Bupivacaine (12.5 mg) and morphine (2 mg) were administered epidurally to all patients at the end of operation. Patients in the magnesium (Mg) group received epidural magnesium sulphate (50 mg), and patients in the control (C) group received normal saline as an adjuvant. Visual analogue scale (VAS) score and the amount of morphine consumption were measured during 24 hr post-operation. Thirty-nine patients in the Mg group and 41 patients in the C group completed the study. Patients in the Mg group had significantly less VAS score at recovery time (p < 0.05), 2 hr (p < 0.01) and 4 hr (p < 0.05) after surgery. The patient-controlled analgesia pump was started earlier in the C group than in the Mg group (p < 0.05). The amount of morphine needed in the Mg group was significantly lower than in the C group (5.64 ± 1.69 mg/24 hr versus 8.44 ± 3.98 mg/24 hr; p < 0.001). Pruritus was seen in the C group (9.7%) and absent in the Mg group (p < 0.05). Co-administration of magnesium sulphate with bupivacaine and morphine for thoracic epidural analgesia after thoracotomy leads to a reduction in post-operative pain score and the need for opioid administration.
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http://dx.doi.org/10.1111/bcpt.13047DOI Listing
November 2018

Investigating PIKR and ATpA Genes Expressions in Ventilator-Associated Pneumonia Patients Admitted to the Intensive Care Unit of Masih Daneshvari Hospital in 2016.

Rep Biochem Mol Biol 2018 Apr;6(2):118-124

Virology Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran. Department of Biotechnology, School of Advanced Technologies in Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Infectious diseases such as ventilator- associated pneumonia (VAP) are one of the serious problems in intensive care units (ICU) of hospitals. To date, there has been no appropriate clinical and diagnostic marker for early detection of this disease. In this study, expression of PIKR and ATpA genes in patients with VAP were assessed to be used as biomarkers to identify and confirm the disease.

Methods: This study was conducted by using peripheral blood samples of 60 individuals, including 30 patients with VAP and 30 healthy volunteers. First, the peripheral blood samples were taken and then RNA was extracted and converted into cDNA. Finally, the assessment of genes was performed by Real-time PCR.

Results: In peripheral blood samples, 46.6% and 30% were positive for PIKR expression in patients and healthy groups, respectively. The ATpA expression in patients and healthy controls were found 40% and 23.3%, respectively. Comparing the ΔCT obtained for the PIKR and ATpA genes showed statistically significant differences between the two groups of patients and healthy subjects (p=0.042, p=0.036).

Conclusion: ATpA and PIKR may be used as biomarkers for early detection of VAP disease. However, further studies are required.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5941122PMC
April 2018

An eleven-year retrospective cross-sectional study on pulmonary alveolar proteinosis.

Adv Respir Med 2018 ;86(1):7-12

Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Introduction: Pulmonary alveolar proteinosis (PAP) is a rare disease in the field of pulmonary medicine. The efficacy of whole-lung lavage (WLL) as the treatment of PAP had never been evaluated in the Iranian population. Therefore, there is a real need to investigate the characteristics of PAP and also to evaluate the efficacy of WLL in this rare disease. The study aimed to investigate demographic features, clinical presentation and treatment outcomes of the disease in Iranian PAP patients.

Material And Methods: Data of 45 patients with definite diagnosis of PAP, who had regular follow-ups from March 2004 to March 2015 at an Iranian referral respiratory hospital, were collected. Whole-lung lavages (WLL) efficacy was assessed by comparing spirometric, arterial blood gas parameters and six-minute walk test (6MWT) results before and after all lavages.

Results: Mean age at diagnosis of disease was 30.33 ± 14.56 years. Four patients (8.8%) reported non-massive hemoptysis and three subjects (6.6%) had concomitant pulmonary tuberculosis. In 71.1% of cases, transbronchial lung biopsy and bronchoalveolar lavage were sufficient for diagnosis. Spirometric results and arterial blood gas parameters and 6MWD improved significantly after all the lavages. Four patients (8.8%) died because of respiratory failure. The only variable capable of predicting treatment failure was the history of hemoptysis.

Conclusion: The study revealed sufficiency of WLL as the PAP patients' treatment. Also hemoptysis was found to be the independent factor that can predict treatment failure.
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http://dx.doi.org/10.5603/ARM.2018.0003DOI Listing
September 2018

Spiritual Health and Outcomes in Muslim ICU Patients: A Nationwide Cross-Sectional Study.

J Relig Health 2018 Dec;57(6):2241-2257

Department of Emergency Medicine, Vidant Medical Center, East Carolina University Brody School of Medicine, 600 Moye Blvd, Greenville, NC, 27834, USA.

The aim of the present study is to describe how religiosity and spirituality affect the psychiatric morbidity of Muslim intensive care unit (ICU) patients. We conducted a prospective nationwide cross-sectional study of ICU patients discharged from 45 medical centers spanning 31 proivinces in Iran. Adults (age ≥ 18 years) admitted to the ICU and treated with invasive mechanical ventilation were eligible. Nine validated survey tools were administered to detect direct and indirect associations between spiritual health (SH) and depression, anxiety, and post-traumatic disorder. The Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale-Revised (IES-R), Post-Traumatic Stress Syndrome 14 question (PTSS-14) quality-of-life (QoL), and quality of patient to physician or nurse communication (PP-QoC and PN-QoC) scales were modeled through two mediators by structural equation modeling (SEM). Sex, ICU type, LOS, and APACHE II score were added in the independent variable list. 338 eligible patients were discharged from the ICUs during the study period. 56 were excluded (clinical status), and 282 were administered the survey. 278 returned it, with 272 complete and 6 partial responses. SH displayed no direct or indirect association to QoL. SH was indirectly associated with decreased depression and anxiety (B = - 0.081, p < 0.05) via PP-QoC mediator. Both direct and indirect positive associations were observed between SH and IES-R (B = 0.293, p < 0.05; via PP-QoC) and PTSS-14 scores (B = 0.267, p < 0.001; via PP-QoC). Medical ICU location was associated with decreased PTSS-14 scores via the same mediator. In this survey of Muslim ICU patients treated with invasive mechanical ventilation, SH correlated with decreased depression and anxiety, but paradoxically increased post-traumatic stress. The most influential mediator was patient-physician quality-of-communication.
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http://dx.doi.org/10.1007/s10943-017-0543-5DOI Listing
December 2018

Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium.

J Crit Care 2018 Feb 24;43:88-94. Epub 2017 Aug 24.

Department of Emergency Medicine, J.W. Ruby Memorial Hospital, West Virginia University, Morgantown, WV, USA; Department of Emergency Medicine, Vident Medical Center, East Carolina University, Greenville, NC, USA. Electronic address:

Purpose: We investigated the impact of delirium on illness severity, psychological state, and memory in acute respiratory distress syndrome patients with very long ICU stay.

Materials And Methods: Prospective cohort study in the medical-surgical ICUs of 2 teaching hospitals. Very long ICU stay (>75days) and prolonged delirium (≥40days) thresholds were determined by ROC analysis. Subjects were ≥18years, full-code, and provided informed consent. Illness severity was assessed using Acute Physiology and Chronic Health Evaluation IV, Simplified Acute Physiology Score-3, and Sequential Organ Failure Assessment scores. Psychological impact was assessed using the Hospital Anxiety and Depression Scale, Impact of Event Scale-Revised, and the 14-question Post-Traumatic Stress Syndrome (PTSS-14). Memory was assessed using the ICU Memory Tool survey.

Results: 181 subjects were included. Illness severity did not correlate with delirium duration. On logistic regression, only PTSS-14<49 correlated with delirium (p=0.001; 95% CI 1.011, 1.041). 49% remembered their ICU stay clearly. 47% had delusional memories, 50% reported intrusive memories, and 44% reported unexplained feelings of panic or apprehension.

Conclusion: Delirium was associated with memory impairment and PTSS-14 scores suggestive of PTSD, but not illness severity.
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http://dx.doi.org/10.1016/j.jcrc.2017.08.034DOI Listing
February 2018

Item Selection and Content Validity of the Risk Factors of Post-Intubation Tracheal Stenosis Observation Questionnaire for ICU-Admitted Patients.

Tanaffos 2017 ;16(1):22-33

Tracheal Diseases Research Center (TDRC), National Research Institute of Tuberculosis and Lung disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Laryngotracheal stenosis as a late complication of prolonged endotracheal intubation is a life-threatening event. In order to determine the related risk factors for this complication, which may vary among different countries, designing a valid questionnaire is necessary. The aim of this study was to select the items and evaluate the face and content validities of a questionnaire developed for assessment of risk factors of post-intubation tracheal stenosis (PITS) in patients admitted in the intensive care unit.

Materials And Methods: A mixed method study design was used in four steps in 2015, i.e., 1) a literature review, 2) focus groups with five experts in the field, 3) consultations with intensive care unit (ICU) specialists and thoracic surgeons, and 4) evaluation of content and face validity with 15 experts in a scientific panel using two self-administered questionnaires. Content validity index (CVI) was computed for individual items as well as the overall scale.

Results: We extracted the items from different sources of information. An initial version of the 52-item questionnaire was developed and classified into four domains including patient characteristics, intubation features, equipment-drugs, and complications. The items with an excellent modified kappa were included in the questionnaire. Five questions received more criticism instead of support and were removed (Item-CVI<0.55, fair modified kappa). The ones with an Item-CVI > 0.60 and a good modified kappa were revised, merged, or retained. The new 43-item questionnaire found a scale-level CVI, averaging (Scale-CVI/Ave) of 0.91.

Conclusion: The PITS risk factors questionnaire was developed and validated through item selection, expert opinions, and content validity index.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5473379PMC
January 2017

Incidence Rate of Post-Intubation Tracheal Stenosis in Patients Admitted to Five Intensive Care Units in Iran.

Iran Red Crescent Med J 2016 Sep 2;18(9):e37574. Epub 2016 Aug 2.

Tracheal Diseases Research Center (TDRC), National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, IR Iran.

Background: Tracheal stenosis is one of the worst complications associated with endotracheal intubation and it is the most common reason for reconstructive airway surgeries. Due to various local risk factors, the incidence rate of tracheal stenosis may vary in different countries. In order to estimate the incidence rate of post-intubation tracheal stenosis (PITS) in patients admitted to an intensive care unit (ICU), a follow-up study was planned. As there was no similar methodological model in the literature, a feasibility step was also designed to examine the whole project and to enhance the follow-up rate.

Objectives: To estimate the PITS incidence rate in patients admitted to ICUs, as well as to evaluate the feasibility of the study.

Methods: This prospective cohort study was conducted in five hospitals in two provinces (Tehran and Arak) of Iran from November 2011 to March 2013. All patients admitted to ICUs who underwent more than 24 hours of endotracheal intubation were included. Upon their discharge from the ICUs, the patients received oral and written educational materials intended to ensure a more successful follow-up. The patients were asked to come back for follow-up three months after their extubation, or sooner in case of any symptoms developing. Those with dyspnea or stridor underwent a bronchoscopy. The asymptomatic patients were given a spirometry and then they underwent a bronchoscopy if the flow-volume loop suggested airway stenosis.

Results: Some seventy-three patients (70% men) were included in the study. Multiple trauma secondary to motor vehicle accidents (52%) was the most common cause of intubation. Follow-ups were completed in only 14 (19.2%, CI = 0.109 - 0.300) patients. One patient (7%, CI = 0.007 - 0.288) developed symptomatic tracheal stenosis that was confirmed by bronchoscopy. The barriers to a successful follow-up were assessed on three levels: ineffective oral education upon discharge, improper usage of educational materials, and difficulties to attending follow-up visits. There were also some important obstacles in terms of human, time, material, and cost resources, as well as data management.

Conclusions: To enhance the follow-up rate, three strategies were proposed: patient-focused strategies such as emphasizing patient education upon discharge and providing rewards; structural-focused strategies such as scheduling home visits and uploading questionnaires onto the research center's website; and provider-focused strategies such as selecting coordinators with good communication skills. All necessary resources should also be re-arranged for a multicenter national study.
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http://dx.doi.org/10.5812/ircmj.37574DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253460PMC
September 2016

Normothermic Ex Vivo Lung Perfusion in Brain-dead Donors Reduces Inflammatory Cytokines and Toll-like Receptor Expression.

Iran J Allergy Asthma Immunol 2016 Oct;15(5):340-354

Lung Transplant Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran AND Directors of Organ Transplantation and Special Diseases Office, Ministry of Health and Medical Education, Tehran, Iran.

Inflammatory responses and innate immunologic reactions play an important role in the respiratory system. Ex vivo lung perfusion (EVLP) is considered a novel method in the evaluation and reconditioning of donor lungs prior to transplantation. However, EVLP's effect on inflammatory and metabolic markers of human lung tissue is unknown.  This study investigated how the performance of EVLP on brain-dead (BD) donor lungs affects the production and release of inflammatory cytokines (IL-6, IL-8, and TNF-a), inflammatory cells and toll-like receptors (TLR) -2, 4. This study was conducted with an animal subject for qualification of EVLP team and then EVLP was performed on 4 human cases referred to Masih Daneshvari Hospital (Tehran,Iran), from May 2013 to July 2015. Two of these cases, who had acceptable lung function parameters, were enrolled in this study for immunologic investigations. Bronchoalveolar lavages (BAL) were taken before and after EVLP. Cytokines were quantitatively measured before lung retrieval, at the end of the lung removal, at the start of EVLP, and at the end of the each hour of EVLP. TLR expression was measured on the cells obtained by flow cytometry. TNF-a, IL-6 and IL-8 decreased in each stage of washing perfusate in both cases, and the level of cytokines in serum was in the normal range. Flow cytometry analysis revealed a decreasing expression of CD3, CD4/8, CD19, and CD16+56, as well as TLR-2 and TLR-4 in both cases. Intra-capillary pools of pro-inflammatory cytokines (IL-6, IL-8, and TNF-a) were determined to contribute to the lung injury during prolonged lung perfusion. This raises the possibility that EVLP donor lungs could be less immunogenic than standard lungs. However, to assess EVLP's effects on lung grafts and optimize recipient outcomes, further studies with a sufficient number of lungs are required.
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October 2016

Ex Vivo Lung Perfusion: Establishment and Operationalization in Iran.

Exp Clin Transplant 2017 Feb 14;15(1):82-88. Epub 2016 Oct 14.

From the Lung Transplant Research Center, National Research Institute of Tuberculosis and Lung Disease (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Objectives: Although the number of lung transplants is limited because of general shortage of organ donors, ex vivo lung perfusion is a novel method with 2 main benefits, including better evaluation of lung potential and recovery of injured lungs. The main aim of this study was to establish and operationalize ex vivo lung perfusion as the first experience in Iran.

Materials And Methods: This was a prospective operational research study on 5 cases, including 1 pig from Vienna Medical University and 4 patients from Masih Daneshvari Hospital. All organ donations from brain dead donors were evaluated according to lung transplant or ex vivo lung perfusion criteria from May 2013 to July 2015 in Tehran, Iran. If a donor did not have any sign of severe chest trauma or pneumonia but had poor oxygenation due to possible atelectasis or neurogenic pulmonary edema, their lungs were included for ex vivo lung perfusion.

Results: A successful trend in the difference between the pulmonary arterial Po2 and the left atrial Po2 was observed, as well as an increasing pattern in other functional parameters, including dynamic lung compliance and a decreasing trend in pulmonary vascular resistance.

Conclusions: These initial trials indicate that ex vivo lung perfusion can lead to remarkable progress in lung transplant in Iran. They also provide several important pieces of guidance for successful ex vivo lung perfusion, including the necessity of following standard lung retrieval procedures and monitoring temperature and pressure precisely. The development of novel methods can provide opportunities for further research studies on lungs of deceased donors and lead to undiscovered findings. By keeping this science up to date in Iran and developing such new and creative methods, we can reveal effective strategies to promote the quality of donor lungs to support patients on transplant wait lists.
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http://dx.doi.org/10.6002/ect.2015.0354DOI Listing
February 2017