The Egyptian Journal of Chest Diseases and Tuberculosis (Egypt J Chest Dis Tuberc)

Efficacy and troubleshooting of noninvasive ventilation Khaled Hussein The Egyptian Journal of Chest Diseases and Tuberculosis 2018 67(4):333-340 Noninvasive positive pressure ventilation (NPPV) means application of ventilation through patient’s upper airway by an interface without an endotracheal tubeortracheostomy. The efficacy of NPPV depends on the selection of equipment and interface, good clinician experience,and meticulous monitoring during NPPV. Several interfaces are available with nasal and oronasal types are the most common. The most common troubleshooting of NPPV are leak, CO2 rebreathing, mask problems, and asynchrony.

Assessment of cognitive dysfunction, depression, and anxiety in patients with stable chronic obstructive pulmonary disease in relation to serum interleukin-6 Samah M Shehata, Ahmad Abbas, Hala A Fathy, Ghada M Salah El-Deen, Amany M Sediq The Egyptian Journal of Chest Diseases and Tuberculosis 2018 67(4):341-350 Background Chronic obstructive pulmonary disease (COPD) is a well-recognized multicomponent disease, but its influences on cognitive function and other associated psychological disorders were poorly identified. Systemic inflammation is considered as a key link between these diseases. Aim To assess the cognitive impairment, anxiety, and depression among stable COPD patients using different neuropsychological tests, in relation with serum interleukin-6 (IL-6). Patients and methods A study was conducted upon 100 stable COPD patients and 25 controls. All the participants were subjected to neurological and psychiatric assessment, such as The Generalized Anxiety Disorder-7 scale, Beck Depression Inventory-II scale, and Montreal Cognitive Assessment scale. Serum IL-6 was measured for all participants. Results COPD patients had more frequent anxiety disorders, depression, cognitive dysfunction, and higher serum IL-6 than control group. Visual-spatial/executive and delayed recall domains of cognitive dysfunction were significantly affected in COPD than controls (P<0.001), whereas other domains (Naming, Attention, Language, Abstraction, and Orientation) did not reach a significant level of statistical difference. Generalized Anxiety Disorder-7 anxiety score showed a significant positive correlation with modified medical research council and serum IL-6 and a significant negative correlation with forced expiratory volume in the first second%. Beck Depression Inventory-II score showed a significant positive correlation with BMI. Montreal Cognitive Assessment score showed a significant positive correlation with forced expiratory volume in the first second% and a significant negative correlation with serum IL-6. A cut-off value of serum IL-6 more than 2.6 pg/ml had sensitivity and specificity for prediction of cognitive dysfunction in COPD patients (86.1 and 66.7%, respectively; P<0.001). Conclusion Anxiety, depression, and cognitive impairment were significantly more prevalent between COPD patients. Serum IL-6 was a valid predictor for cognitive dysfunction in COPD patients.

Downregulation of regulatory T cells in patients with chronic obstructive pulmonary disease: relation to disease severity Mohamed F.A Ghany, Hoda A Makhlouf, Noha Gaber The Egyptian Journal of Chest Diseases and Tuberculosis 2018 67(4):351-355 Bachground Chronic obstructive pulmonary disease (COPD) is a slowly progressing disease that has the characteristics of chronic inflammation of the airways and destruction of lung parenchyma; the pathogenesis of which is partially understood. COPD might have an autoimmune pathogenesis. It has been documented that disturbance of CD4+ T-regulatory (Treg) lymphocytes leads to breakdown of self-tolerance and development of many diseases. Limited data are available about the role of Treg cells in COPD. Objective To determine the role of Treg cells in the pathogenesis and severity of COPD. Patients and methods This prospective case–control study was conducted on 34 patients with COPD and 48 healthy controls (24 smokers and 24 never-smokers). Flow cytometry analysis for Treg cells was used. Results CD4+CD25high cells percentage and cytoplasmic forkhead box protein P3 expression were significantly lower in COPD compared with healthy controls, either nonsmokers or smokers (P<0.05). Accordingly, both the percentage of cytoplasmic forkhead box protein P3 expression and its mean fluorescent intensity were significantly lower in patients with COPD compared with the nonsmokers and smokers (P=0.011, 0.002 and 0.002, respectively). A significant positive correlation between CD4+CD25high percentage and either forced expiratory volume in one second percentage predicted and forced expiratory volume in one second/forced vital capacity ratio was detected (r=691, P<0.001; r=729, P<0.001). Conclusion There is downregulation of Treg cells in COPD, and this could play a role in the pathogenesis of COPD.

Characteristic features and percentage of asthma chronic obstructive pulmonary disease overlap among patients with obstructive airway diseases Ahmed Al Halfawy, Hamed Abdelhafiz, Eman Kamal, Mohamed Gaber The Egyptian Journal of Chest Diseases and Tuberculosis 2018 67(4):356-360 Background Asthma and chronic obstructive pulmonary disease (ACO) were considered two different diseases, but recently it was found that some patients have features of both asthma and chronic obstructive pulmonary disease (COPD), and they were defined as having ACO. Aim To study the characteristics features of ACO and its percentage among obstructive airway diseases and to assess sputum eosinophils in these patients. Patients and methods The study included 56 patient attending Kasr Al Aini outpatient clinic who were diagnosed as having obstructive airway diseases (asthma, COPD and ACO). Patients enrolled in the study were subjected to full history taking, clinical examination, full laboratory examination, plain chest radiography, spirometry before bronchodilator and after bronchodilator administration (reversibility test) and sputum analysis for counting eosinophils cells. Patients were classified into three groups (asthma, COPD and ACO). Results This study was conducted on 56 patients, including 47 (83.9%) males and nine (16.1%) females. Among the studied patients, 23 (41.1%) patients were diagnosed as ACO. The mean age of patients with ACO was 53.43±11 years. The age of onset of symptoms was below 40 years in 43.5% of patients with ACO and above 40 years in 56.5% of them. Eighty-seven percent of ACO group were smokers, 60.9% had history of atopy and 26.1% had sputum eosinophilia. Conclusion ACO represents a large percentage among patients with obstructive airway diseases. It shares some features of asthma such as atopy and positive sputum eosinophilia, and some features of COPD like old age of presentation and positive smoking history.

Predictors of mortality in patients with acute exacerbation of chronic obstructive pulmonary disease requiring ICU admission Asmita Mehta The Egyptian Journal of Chest Diseases and Tuberculosis 2018 67(4):361-367 Background Acute exacerbations are associated with significant morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD). Identification of mortality predictors in severe COPD exacerbations may be of use in clinical decision making and prognostication. Objective The aim was to determine the in-hospital mortality rate, predictors of 30-day mortality, and duration of mechanical ventilation in patients admitted to the ICU with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Materials and methods This was an observational study conducted in a tertiary care hospital. Patients with acute exacerbation of COPD needing ICU admission were included. A standardized questionnaire was prepared to collect information about included patients. Outcomes of interest were total duration of hospital stay, ICU stay or death. SPSS version 11 was used for the statistical analysis. Results A total of 63 patients were enrolled in the study, out of which 22 (34.9%) died. Sepsis with multiorgan failure was commonest cause of the death. The risk factors associated with increased mortality in univariate analysis were pH less than 7.25, lymphocyte counts of less than 10%, platelet counts less than 1.5 lac, blood urea greater than 40 mg/dl, and need of mechanical ventilation. Multivariate analysis was conducted for those with statistically significant P value in univariate analysis. It showed thrombocytopenia, hypotension, hypercapnea, and uremia were independent predictors of increased mortality. Conclusion The present study revealed a mortality rate of 34.9% in patients with AECOPD needing ICU admission. Thrombocytopenia, hypotension, hypercapnea, and uremia were independent predictors of increased mortality. The results may be useful in the prognostication of patients with AECOPD needing ICU admission.

Thyroid profile in patients with chronic respiratory failure: effect of domiciliary noninvasive positive airway pressure Maha Yousif, Hany A Hussein, Hany S Rasmy, Yasmin N Elsakhawy The Egyptian Journal of Chest Diseases and Tuberculosis 2018 67(4):368-375 Background Various thyroid hormone states have been described in patients with respiratory failure. Domiciliary noninvasive positive airway pressure (NPAP) can be used for management of chronic respiratory failure. Aim This study aims to assess thyroid function in patients with chronic respiratory failure and to evaluate the effect of domiciliary NPAP on thyroid hormone levels. Patients and methods Forty-five patients were admitted with acute on top of chronic respiratory failure of various causes; all were addressed after discharge to domiciliary NPAP, either continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BPAP). Thyroid hormones and arterial blood gas were assessed on admission, at the time of discharge, and at 2-month follow-up. Results On admission, 21 (46.67%) patients had nonthyroidal illness syndrome (NTIS) and eight (17.78%) patients had subclinical hypothyroidism. PO2 level was significantly lower in patients with NTIS than subclinical hypothyroidism, and it correlated positively with thyroid hormone levels. A highly significant increase in PO2 and reduction in PCO2 were found after 2 months of discharge on domiciliary CPAP or BPAP as compared with their levels on discharge and admission. The percentage of change in arterial blood gas and thyroid hormone levels (between admission and 2 months follow-up) when comparing CPAP with BPAP was statistically nonsignificant. Conclusion NTIS and subclinical hypothyroidism can occur in patients with acute-on-chronic respiratory failure correlating with PO2 even in 2-month follow-up period in patients on domiciliary NPAP, with no significant difference between CPAP and BPAP.

Combined microbiological and clinical outcomes of short-term inhaled colistin adjunctive therapy in ventilator-associated pneumonia Yasser S Nassar, Maha Saber-Ayad, Rania Y Shash The Egyptian Journal of Chest Diseases and Tuberculosis 2018 67(4):376-383 Purpose Aerosolized antibiotics have potential lower risks of toxicity. Colistin has an excellent bactericidal activity against most gram-negative bacilli. We aimed to define both microbiological and clinical target outcomes after a 5-day treatment period in the treatment of patients with gram-negative ventilator-associated pneumonia (VAP). Patients and methods We recruited all patients with gram-negative bacteria culture and sensitivity taken from endotracheal tube aspirates after greater than or equal to 48 h of mechanical ventilation and clinical pulmonary infection score (CPIS) greater than or equal to 6. Patients were randomized to enter either the study group of inhaled colistin (3 million IU/day, for 5 days) as an adjunctive therapy to intravenous antibiotic treatment of VAP or enter the control group of intravenous antibiotics only. In both arms, intravenous antibiotics were started from the day of clinical suspicion according to American Thoracic Society/Infectious Disease Society of America guidelines. Interpretations on day 6 included microbiological outcome (endotracheal tube aspirate culture and sensitivity) and CPIS. Favorable outcome was defined if there was a microbiological clearance and CPIS less than 6. Patients were monitored for bronchospasm, daily serum creatinine, days of mechanical ventilation, and 30-day mortality. Results A total of 102 patients were recruited. Colistin group included 52 patients and the control group included 50 patients. Favorable outcome was higher [41 (78.8%) vs. 27 (54%), P=0.02] in colistin versus control group, respectively. Prolonged mechanical ventilation for more than 15 days was lower [23 (44.2%) vs. 44 (88%), P=0.01] and a 30-day hospital mortality was lower [21/52 (40.3%) vs. 35/50 (70%), P=0.008] in colistin versus control group, respectively. Conclusion Five days of adjunctive inhaled colistin in patients with gram-negative VAP showed a higher combined clearance and clinical improvement, including multidrug resistant groups, decreased duration of mechanical ventilation, and ICU mortality when compared with conventional intravenous therapy alone.

Acid–base balance, serum electrolytes, and need for noninvasive ventilation in patients with hypercapnic acute exacerbation of chronic obstructive pulmonary disease Magdi A Lolah, Mahmoud M El-Habashy, Ghada A.M Arafa The Egyptian Journal of Chest Diseases and Tuberculosis 2018 67(4):384-389 Context Chronic obstructive pulmonary disease (COPD) is a common disease with major morbidity and mortality. Hypoventilation occurring with hypercapnia of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) worsens respiratory acidosis in patients. In these patients, acid–base (AB) balance and electrolytes are closely related and affect the patient outcome. Noninvasive ventilation (NIV) use in the management of acute exacerbation improves patients’ respiratory function and decreases complications. Aim To detect the effect of AB and electrolyte disorders in patients with hypercapnic COPD exacerbation, and the effect of the treatment type on the AB and electrolyte disorders. This is a prospective study conducted in the Chest Department of Menoufia University Hospital. Patients and methods We analyzed 110 patients admitted to the Chest Department of Menoufia University Hospital for hypercapnic AECOPD. On admission, all patients underwent history taking, full examination, and arterial blood gas analysis and received oxygen with nasal cannulae or a venturi mask to preserve normal oxygen saturation, as well as received pharmacological treatment. NIV was started when patients had severe dyspnea, increased work of breathing, and respiratory acidosis despite optimum management. Results Based on arterial blood gas finding, we categorized our patients into three main groups: group A had 61 patients with compensated respiratory acidosis; group B had 28 patients with respiratory acidosis+metabolic alkalosis; and group C had 21 patients with respiratory acidosis+metabolic acidosis. A total of 56 patients received pharmacological therapy, and 54 also needed NIV. The use of NIV support was lower in the patients belonging to group A than in those belonging to groups B and C (25.9 vs. 40 and 33.3%, respectively; P<0.001). Conclusion AB balance greatly affects the treatment of patient with AECOPD. The combined metabolic and respiratory acidosis increases the need of NIV and its failure.

Comparison between some techniques used for early detection of ventilator-associated infection Hoda A.A Abo Youssef, Amany A Abo Zaid, Mohamed W Zakaria, Amany A El-Kholy, Yasmine H El-Hinnawy, Gihan S Abo El Wafa The Egyptian Journal of Chest Diseases and Tuberculosis 2018 67(4):390-393 Background Although mechanical ventilation could be lifesaving, yet it could be the cause of death owing to its complications. One of the reasons of death is the infection being challenging to the clinicians to diagnose owing to the clinical variability and a wide scale of diseases causing fever and chest infiltrates. The earlier the established diagnosis and proper therapy, the better the outcome. The objective was to compare between different methods used for the early diagnosis of ventilator-associated infection. Patients and methods The study included 50 patients mechanically ventilated for 72 h. The patients were subjected to basic clinical data collection, laboratory investigations, chest radiography, endotracheal aspiration (ETA), and bronchoalveolar lavage (BAL). Direct Gram stain and bacterial culture were done for both the aspirate and the lavage fluid. Results and conclusion A total of 27 patients were found to be infected. Agreement between direct Gram staining and bacterial culture of ETA was recorded in 64% of the cases, whereas the agreement with BAL was recorded in 76%. Overall agreement between ETA and BAL culture results was seen in 44%. From the previous results, ETA should not replace BAL as a diagnostic modality.

Clinical and investigational profiles of elevated pulmonary artery pressures in patients with stable chronic obstructive pulmonary diseases Mohammed A Agha, Maha Yousif, Rehab M Habib, Waleed Abdou, Nesreen G El-Helbawy The Egyptian Journal of Chest Diseases and Tuberculosis 2018 67(4):394-400 Background Pulmonary hypertension (PH) is a major predictor of exercise tolerance and mortality in chronic obstructive pulmonary disease (COPD). The confirmatory and gold standard is the right heart catheterization. Noninvasive, simple and readily available parameters to frequently monitor patients with COPD are much needed. Objective To evaluate various clinical and investigational parameters such as BMI, airway obstruction, dyspnea, and exercise [BODE index capacity by 6-minutes walking test (6MWT)], computed tomography (CT) pulmonary artery/ascending aorta ratio (PA/AO), and serum ghrelin in patients with COPD with elevated PA pressures in different disease stages. Patient and methods A total of 40 patients with stable COPD were classified into two groups, group I patients without PH and group II patients with PH, according to echocardiographic measures. All patients are subjected to calculation of BODE index, serum ghrelin levels, and CT PA/AO. Results There was a significant difference between both groups regarding BODE index, PA/AO, serum ghrelin level, and post-MWT O2 saturation. There were positive significant correlations between the mean PA pressure and BODE index, PA/AO ratio, and serum ghrelin level. However, there were negative significant correlations regarding resting PaO2, post-6MWT O2, and pulmonary function tests. The cutoff value of PA/AO ratio was 0.84 in diagnosing PH with 95% sensitivity and 80% specificity, and the cutoff value of serum ghrelin level was 1694 ng/l in diagnosing PH with 98% sensitivity and 88% specificity. Conclusion BODE index, CT PA/AO ratio, post-6MWT oxygen saturation, and serum ghrelin level are useful noninvasive predictors for PH. A cutoff point of PA/AO of 0.84 and ghrelin of more than 1712 ng/l can be used for detection of elevated PA pressures in those patients.

REVIEW ARTICLE
	Efficacy and troubleshooting of noninvasive ventilation	p. 333
	Khaled Hussein DOI:10.4103/ejcdt.ejcdt_105_18   Noninvasive positive pressure ventilation (NPPV) means application of ventilation through patient’s upper airway by an interface without an endotracheal tubeortracheostomy. The efficacy of NPPV depends on the selection of equipment and interface, good clinician experience,and meticulous monitoring during NPPV. Several interfaces are available with nasal and oronasal types are the most common. The most common troubleshooting of NPPV are leak, CO2 rebreathing, mask problems, and asynchrony.
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ORIGINAL ARTICLES: COPD
	Assessment of cognitive dysfunction, depression, and anxiety in patients with stable chronic obstructive pulmonary disease in relation to serum interleukin-6	p. 341
	Samah M Shehata, Ahmad Abbas, Hala A Fathy, Ghada M Salah El-Deen, Amany M Sediq DOI:10.4103/ejcdt.ejcdt_68_18   Background Chronic obstructive pulmonary disease (COPD) is a well-recognized multicomponent disease, but its influences on cognitive function and other associated psychological disorders were poorly identified. Systemic inflammation is considered as a key link between these diseases. Aim To assess the cognitive impairment, anxiety, and depression among stable COPD patients using different neuropsychological tests, in relation with serum interleukin-6 (IL-6). Patients and methods A study was conducted upon 100 stable COPD patients and 25 controls. All the participants were subjected to neurological and psychiatric assessment, such as The Generalized Anxiety Disorder-7 scale, Beck Depression Inventory-II scale, and Montreal Cognitive Assessment scale. Serum IL-6 was measured for all participants. Results COPD patients had more frequent anxiety disorders, depression, cognitive dysfunction, and higher serum IL-6 than control group. Visual-spatial/executive and delayed recall domains of cognitive dysfunction were significantly affected in COPD than controls (P<0.001), whereas other domains (Naming, Attention, Language, Abstraction, and Orientation) did not reach a significant level of statistical difference. Generalized Anxiety Disorder-7 anxiety score showed a significant positive correlation with modified medical research council and serum IL-6 and a significant negative correlation with forced expiratory volume in the first second%. Beck Depression Inventory-II score showed a significant positive correlation with BMI. Montreal Cognitive Assessment score showed a significant positive correlation with forced expiratory volume in the first second% and a significant negative correlation with serum IL-6. A cut-off value of serum IL-6 more than 2.6 pg/ml had sensitivity and specificity for prediction of cognitive dysfunction in COPD patients (86.1 and 66.7%, respectively; P<0.001). Conclusion Anxiety, depression, and cognitive impairment were significantly more prevalent between COPD patients. Serum IL-6 was a valid predictor for cognitive dysfunction in COPD patients.
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	Downregulation of regulatory T cells in patients with chronic obstructive pulmonary disease: relation to disease severity	p. 351
	Mohamed F.A Ghany, Hoda A Makhlouf, Noha Gaber DOI:10.4103/ejcdt.ejcdt_63_18   Bachground Chronic obstructive pulmonary disease (COPD) is a slowly progressing disease that has the characteristics of chronic inflammation of the airways and destruction of lung parenchyma; the pathogenesis of which is partially understood. COPD might have an autoimmune pathogenesis. It has been documented that disturbance of CD4+ T-regulatory (Treg) lymphocytes leads to breakdown of self-tolerance and development of many diseases. Limited data are available about the role of Treg cells in COPD. Objective To determine the role of Treg cells in the pathogenesis and severity of COPD. Patients and methods This prospective case–control study was conducted on 34 patients with COPD and 48 healthy controls (24 smokers and 24 never-smokers). Flow cytometry analysis for Treg cells was used. Results CD4+CD25high cells percentage and cytoplasmic forkhead box protein P3 expression were significantly lower in COPD compared with healthy controls, either nonsmokers or smokers (P<0.05). Accordingly, both the percentage of cytoplasmic forkhead box protein P3 expression and its mean fluorescent intensity were significantly lower in patients with COPD compared with the nonsmokers and smokers (P=0.011, 0.002 and 0.002, respectively). A significant positive correlation between CD4+CD25high percentage and either forced expiratory volume in one second percentage predicted and forced expiratory volume in one second/forced vital capacity ratio was detected (r=691, P<0.001; r=729, P<0.001).Conclusion There is downregulation of Treg cells in COPD, and this could play a role in the pathogenesis of COPD.
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	Characteristic features and percentage of asthma chronic obstructive pulmonary disease overlap among patients with obstructive airway diseases	p. 356
	Ahmed Al Halfawy, Hamed Abdelhafiz, Eman Kamal, Mohamed Gaber DOI:10.4103/ejcdt.ejcdt_101_18   Background Asthma and chronic obstructive pulmonary disease (ACO) were considered two different diseases, but recently it was found that some patients have features of both asthma and chronic obstructive pulmonary disease (COPD), and they were defined as having ACO. Aim To study the characteristics features of ACO and its percentage among obstructive airway diseases and to assess sputum eosinophils in these patients. Patients and methods The study included 56 patient attending Kasr Al Aini outpatient clinic who were diagnosed as having obstructive airway diseases (asthma, COPD and ACO). Patients enrolled in the study were subjected to full history taking, clinical examination, full laboratory examination, plain chest radiography, spirometry before bronchodilator and after bronchodilator administration (reversibility test) and sputum analysis for counting eosinophils cells. Patients were classified into three groups (asthma, COPD and ACO). Results This study was conducted on 56 patients, including 47 (83.9%) males and nine (16.1%) females. Among the studied patients, 23 (41.1%) patients were diagnosed as ACO. The mean age of patients with ACO was 53.43±11 years. The age of onset of symptoms was below 40 years in 43.5% of patients with ACO and above 40 years in 56.5% of them. Eighty-seven percent of ACO group were smokers, 60.9% had history of atopy and 26.1% had sputum eosinophilia. Conclusion ACO represents a large percentage among patients with obstructive airway diseases. It shares some features of asthma such as atopy and positive sputum eosinophilia, and some features of COPD like old age of presentation and positive smoking history.
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	Predictors of mortality in patients with acute exacerbation of chronic obstructive pulmonary disease requiring ICU admission	p. 361
	Asmita Mehta DOI:10.4103/ejcdt.ejcdt_85_18   Background Acute exacerbations are associated with significant morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD). Identification of mortality predictors in severe COPD exacerbations may be of use in clinical decision making and prognostication. Objective The aim was to determine the in-hospital mortality rate, predictors of 30-day mortality, and duration of mechanical ventilation in patients admitted to the ICU with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Materials and methods This was an observational study conducted in a tertiary care hospital. Patients with acute exacerbation of COPD needing ICU admission were included. A standardized questionnaire was prepared to collect information about included patients. Outcomes of interest were total duration of hospital stay, ICU stay or death. SPSS version 11 was used for the statistical analysis. Results A total of 63 patients were enrolled in the study, out of which 22 (34.9%) died. Sepsis with multiorgan failure was commonest cause of the death. The risk factors associated with increased mortality in univariate analysis were pH less than 7.25, lymphocyte counts of less than 10%, platelet counts less than 1.5 lac, blood urea greater than 40 mg/dl, and need of mechanical ventilation. Multivariate analysis was conducted for those with statistically significant P value in univariate analysis. It showed thrombocytopenia, hypotension, hypercapnea, and uremia were independent predictors of increased mortality.Conclusion The present study revealed a mortality rate of 34.9% in patients with AECOPD needing ICU admission. Thrombocytopenia, hypotension, hypercapnea, and uremia were independent predictors of increased mortality. The results may be useful in the prognostication of patients with AECOPD needing ICU admission.
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ORIGINAL ARTICLES: RICU
	Thyroid profile in patients with chronic respiratory failure: effect of domiciliary noninvasive positive airway pressure	p. 368
	Maha Yousif, Hany A Hussein, Hany S Rasmy, Yasmin N Elsakhawy DOI:10.4103/ejcdt.ejcdt_45_18   Background Various thyroid hormone states have been described in patients with respiratory failure. Domiciliary noninvasive positive airway pressure (NPAP) can be used for management of chronic respiratory failure. AimThis study aims to assess thyroid function in patients with chronic respiratory failure and to evaluate the effect of domiciliary NPAP on thyroid hormone levels. Patients and methods Forty-five patients were admitted with acute on top of chronic respiratory failure of various causes; all were addressed after discharge to domiciliary NPAP, either continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BPAP). Thyroid hormones and arterial blood gas were assessed on admission, at the time of discharge, and at 2-month follow-up. ResultsOn admission, 21 (46.67%) patients had nonthyroidal illness syndrome (NTIS) and eight (17.78%) patients had subclinical hypothyroidism. PO2 level was significantly lower in patients with NTIS than subclinical hypothyroidism, and it correlated positively with thyroid hormone levels. A highly significant increase in PO2 and reduction in PCO2 were found after 2 months of discharge on domiciliary CPAP or BPAP as compared with their levels on discharge and admission. The percentage of change in arterial blood gas and thyroid hormone levels (between admission and 2 months follow-up) when comparing CPAP with BPAP was statistically nonsignificant.Conclusion NTIS and subclinical hypothyroidism can occur in patients with acute-on-chronic respiratory failure correlating with PO2 even in 2-month follow-up period in patients on domiciliary NPAP, with no significant difference between CPAP and BPAP.
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	Combined microbiological and clinical outcomes of short-term inhaled colistin adjunctive therapy in ventilator-associated pneumonia	p. 376
	Yasser S Nassar, Maha Saber-Ayad, Rania Y Shash DOI:10.4103/ejcdt.ejcdt_73_18   Purpose Aerosolized antibiotics have potential lower risks of toxicity. Colistin has an excellent bactericidal activity against most gram-negative bacilli. We aimed to define both microbiological and clinical target outcomes after a 5-day treatment period in the treatment of patients with gram-negative ventilator-associated pneumonia (VAP). Patients and methods We recruited all patients with gram-negative bacteria culture and sensitivity taken from endotracheal tube aspirates after greater than or equal to 48 h of mechanical ventilation and clinical pulmonary infection score (CPIS) greater than or equal to 6. Patients were randomized to enter either the study group of inhaled colistin (3 million IU/day, for 5 days) as an adjunctive therapy to intravenous antibiotic treatment of VAP or enter the control group of intravenous antibiotics only. In both arms, intravenous antibiotics were started from the day of clinical suspicion according to American Thoracic Society/Infectious Disease Society of America guidelines. Interpretations on day 6 included microbiological outcome (endotracheal tube aspirate culture and sensitivity) and CPIS. Favorable outcome was defined if there was a microbiological clearance and CPIS less than 6. Patients were monitored for bronchospasm, daily serum creatinine, days of mechanical ventilation, and 30-day mortality. Results A total of 102 patients were recruited. Colistin group included 52 patients and the control group included 50 patients. Favorable outcome was higher [41 (78.8%) vs. 27 (54%), P=0.02] in colistin versus control group, respectively. Prolonged mechanical ventilation for more than 15 days was lower [23 (44.2%) vs. 44 (88%), P=0.01] and a 30-day hospital mortality was lower [21/52 (40.3%) vs. 35/50 (70%), P=0.008] in colistin versus control group, respectively. Conclusion Five days of adjunctive inhaled colistin in patients with gram-negative VAP showed a higher combined clearance and clinical improvement, including multidrug resistant groups, decreased duration of mechanical ventilation, and ICU mortality when compared with conventional intravenous therapy alone.
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	Acid–base balance, serum electrolytes, and need for noninvasive ventilation in patients with hypercapnic acute exacerbation of chronic obstructive pulmonary disease	p. 384
	Magdi A Lolah, Mahmoud M El-Habashy, Ghada A.M Arafa DOI:10.4103/ejcdt.ejcdt_80_18   Context Chronic obstructive pulmonary disease (COPD) is a common disease with major morbidity and mortality. Hypoventilation occurring with hypercapnia of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) worsens respiratory acidosis in patients. In these patients, acid–base (AB) balance and electrolytes are closely related and affect the patient outcome. Noninvasive ventilation (NIV) use in the management of acute exacerbation improves patients’ respiratory function and decreases complications. Aim To detect the effect of AB and electrolyte disorders in patients with hypercapnic COPD exacerbation, and the effect of the treatment type on the AB and electrolyte disorders. This is a prospective study conducted in the Chest Department of Menoufia University Hospital. Patients and methods We analyzed 110 patients admitted to the Chest Department of Menoufia University Hospital for hypercapnic AECOPD. On admission, all patients underwent history taking, full examination, and arterial blood gas analysis and received oxygen with nasal cannulae or a venturi mask to preserve normal oxygen saturation, as well as received pharmacological treatment. NIV was started when patients had severe dyspnea, increased work of breathing, and respiratory acidosis despite optimum management. Results Based on arterial blood gas finding, we categorized our patients into three main groups: group A had 61 patients with compensated respiratory acidosis; group B had 28 patients with respiratory acidosis+metabolic alkalosis; and group C had 21 patients with respiratory acidosis+metabolic acidosis. A total of 56 patients received pharmacological therapy, and 54 also needed NIV. The use of NIV support was lower in the patients belonging to group A than in those belonging to groups B and C (25.9 vs. 40 and 33.3%, respectively; P<0.001). Conclusion AB balance greatly affects the treatment of patient with AECOPD. The combined metabolic and respiratory acidosis increases the need of NIV and its failure.
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	Comparison between some techniques used for early detection of ventilator-associated infection	p. 390
	Hoda A.A Abo Youssef, Amany A Abo Zaid, Mohamed W Zakaria, Amany A El-Kholy, Yasmine H El-Hinnawy, Gihan S Abo El Wafa DOI:10.4103/ejcdt.ejcdt_54_18   Background Although mechanical ventilation could be lifesaving, yet it could be the cause of death owing to its complications. One of the reasons of death is the infection being challenging to the clinicians to diagnose owing to the clinical variability and a wide scale of diseases causing fever and chest infiltrates. The earlier the established diagnosis and proper therapy, the better the outcome. The objective was to compare between different methods used for the early diagnosis of ventilator-associated infection. Patients and methods The study included 50 patients mechanically ventilated for 72 h. The patients were subjected to basic clinical data collection, laboratory investigations, chest radiography, endotracheal aspiration (ETA), and bronchoalveolar lavage (BAL). Direct Gram stain and bacterial culture were done for both the aspirate and the lavage fluid.Results and conclusion A total of 27 patients were found to be infected. Agreement between direct Gram staining and bacterial culture of ETA was recorded in 64% of the cases, whereas the agreement with BAL was recorded in 76%. Overall agreement between ETA and BAL culture results was seen in 44%. From the previous results, ETA should not replace BAL as a diagnostic modality.
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ORIGINAL ARTICLE: PULMONARY VASCULAR DISEASES
	Clinical and investigational profiles of elevated pulmonary artery pressures in patients with stable chronic obstructive pulmonary diseases	p. 394
	Mohammed A Agha, Maha Yousif, Rehab M Habib, Waleed Abdou, Nesreen G El-Helbawy DOI:10.4103/ejcdt.ejcdt_49_18   Background Pulmonary hypertension (PH) is a major predictor of exercise tolerance and mortality in chronic obstructive pulmonary disease (COPD). The confirmatory and gold standard is the right heart catheterization. Noninvasive, simple and readily available parameters to frequently monitor patients with COPD are much needed. Objective To evaluate various clinical and investigational parameters such as BMI, airway obstruction, dyspnea, and exercise [BODE index capacity by 6-minutes walking test (6MWT)], computed tomography (CT) pulmonary artery/ascending aorta ratio (PA/AO), and serum ghrelin in patients with COPD with elevated PA pressures in different disease stages. Patient and methods A total of 40 patients with stable COPD were classified into two groups, group I patients without PH and group II patients with PH, according to echocardiographic measures. All patients are subjected to calculation of BODE index, serum ghrelin levels, and CT PA/AO. Results There was a significant difference between both groups regarding BODE index, PA/AO, serum ghrelin level, and post-MWT O2 saturation. There were positive significant correlations between the mean PA pressure and BODE index, PA/AO ratio, and serum ghrelin level. However, there were negative significant correlations regarding resting PaO2, post-6MWT O2, and pulmonary function tests. The cutoff value of PA/AO ratio was 0.84 in diagnosing PH with 95% sensitivity and 80% specificity, and the cutoff value of serum ghrelin level was 1694 ng/l in diagnosing PH with 98% sensitivity and 88% specificity. Conclusion BODE index, CT PA/AO ratio, post-6MWT oxygen saturation, and serum ghrelin level are useful noninvasive predictors for PH. A cutoff point of PA/AO of 0.84 and ghrelin of more than 1712 ng/l can be used for detection of elevated PA pressures in those patients.
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	Role of pulmonary rehabilitation in patients with pulmonary arterial hypertension	p. 401
	Gehan M El-Assal, Ayman A.E Farghaly, Nehad M Osman, Mohamed H.A Elghafar DOI:10.4103/ejcdt.ejcdt_89_18   Background Pulmonary arterial hypertension (PAH) causes profound functional limitations and poor quality of life. Advances in clearly defined therapies for PH explored other treatment options aimed at improving the outcomes. Objective The aim was to assess the role of pulmonary rehabilitation in patients with pulmonary arterial hypertension. Patients and methods Twenty patients with PAH (based on their right-heart catheter) on stable disease-targeted medication received a 12-week rehabilitation program at the pulmonary rehabilitation center in Military chest hospital, Cairo, Egypt. Efficacy parameters [arterial blood gases (ABG), 6-min walk test (6MWT), dyspnea score according to Modified Medical Research Council (mMRC) scale, and spirometry] have been evaluated at baseline and after 12 weeks. Results The patients included in this study were 14 female patients and 6 male patients. All the twenty cases were idiopathic PAH. There was a highly statistical significant improvement after a 12-week rehabilitation program, as regards (6MWT) from 374.80±104.61 to 415.80±109.27 meters, P=0.000. Oxygen saturation (SaO2) (with a P<0.01) and spirometric functions as regards FVC% and FEV1% (with P=0.010 and 0.042, respectively) had also improved. Dsypnea score had significantly improved after the rehabilitation program from 2.50 to 1.00, P=0.000. No adverse events were noted during the training sessions. Conclusion Pulmonary rehabilitation as an add-on to medical treatment may improve exercise capacity and the quality of life in patients with PAH. The 6MWT is a reliable and objective measurement of functional capacity and a good indicator of improvement in follow-up patients with PAH.
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	Assessment of glycemic gap as a biomarker of severity and outcome of pulmonary embolism in diabetic patients	p. 406
	Eman Shebl, Ahmad Abbas DOI:10.4103/ejcdt.ejcdt_97_18   Objective The aim was to assess the role of glycemic gap as a biomarker of pulmonary embolism severity and outcome in diabetic patients. Patients Diabetic patients who were 18 years of age or older admitted with confirmed diagnosis of pulmonary embolism (n=280) were included in the study. Methods On admission, blood glucose level was measured. HbA1c was measured. To convert HbA1c levels to the estimated long-term average glucose levels (eAG) for the previous 3 months, the equation AG = 28.7×HbA1c-46.7 was used. From the glucose level at ED admission minus the eAG, the glycemic gap was calculated. The severity of pulmonary embolism was assessed by the pulmonary embolism severity index (PESI). Results There was a significant positive correlation between glycemic gap and the severity of pulmonary embolism and length of hospital stay. There was a significant difference of the glycemic gap between nonsurvivors and survivors (110.3±35.6 vs.48.8±31.3; P< 0.001), patients with and without clinical deterioration (108±34.1 vs. 48.1±31.1; P< 0.001), and patients who needed ICU admission and those who did not need ICU admission (107.3±31.9 vs. 46.2±29.7; P< 0.05). At a cut-off value of glycemic gap of greater than or equal to 79, sensitivity, specificity, positive predictive value, and negative predictive value were 100, 82, 23, and 100%, respectively. Multivariate logistic regression of potential predictors of mortality identified two independent predictors: PESI (P<0.001) and glycemic gap (P=0.042). Conclusion Elevated glycemic gap between serum glucose levels upon admission and the HbA1c-derived average glucose was associated with increased severity and mortality in diabetic patients with pulmonary embolism.
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	Value of thrombolytic therapy for submassive pulmonary embolism patients	p. 413
	Magda A Ahmed, Sherif I Abdelsalam, Rehab A Elmorsy DOI:10.4103/ejcdt.ejcdt_81_18   Background and aim of the study The aim of this study was to assess the value of streptokinase in patients with submassive pulmonary embolism (PE) due to unavailability of tissue plasminogen activator in our locality due to limited income sources. Patients and methods A prospective randomized controlled trial was conducted on a total number of 52 patients with a confirmed diagnosis of submassive PE confirmed by computed tomographic pulmonary angiography were further investigated by echocardiography and cardiac biomarkers after ethical approval from the IRB and confirmed written consent from the patients or first-degree relative. The study was conducted between January 2017 and December 2017, at the Chest Department, Mansoura University Hospitals, and the Cardiology Department, Specialized Internal Medicine Hospital, Faculty of Medicine, Mansoura University. Results Fifty-two patients who were diagnosed as having submassive PE were enrolled; 24 patients were randomized to the thrombolytic group (TG) and 28 to the anticoagulant group (AG) by simple randomization through opening a closed envelope. The two groups were compared as regards demographic data, pulmonary artery systolic pressure (PASP), presence of comorbidities (diabetes mellitus) and presence of malignancy or concomitant deep venous thrombosis as risk factors, and the incidence of unprovoked PE without any statistically significant results.The PASP measured 72 h after therapy in the TG was improved with statistically significant difference when compared with that measured before starting therapy (P<0.001). In contrast, there was no statistically significant difference in the changes in PASP before and after therapy in the AG (P=0.06). Thereafter, PASP measured 72 h after therapy in TG was lower, with statistically significant difference than that measured 72 hours after therapy in AG (P<0.001). As regards the effect of therapy in TG, 12 of 50 still had pulmonary hypertension in the follow-up echocardiography carried out 72 h after starting therapy versus 24 of 28 in AG with statistically significant difference (P=0.003). Moreover, hospital stay in TG was lower than that of AG (6.5±1.5 vs. 7.6±1.66, P=0.013). No bleeding was detected in both groups. ConclusionThrombolytic therapy should be considered over anticoagulation as first-line management in submassive PE causing right ventricular dysfunction without hypotension. Clinical implications Early identification of submassive PE and start of thrombolytic therapy after exclusion of bleeding risk in the patient for thrombolysis can improve outcome and decrease hospital stay.
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ORIGINAL ARTICLE: TUBERCULOSIS
	The role of genexpert in diagnosis of sputum-negative pulmonary tuberculosis	p. 419
	Mohamed Sedky, Ismail Al Wakil, Mohamed Rashed, Ahmed Salama DOI:10.4103/ejcdt.ejcdt_57_18   Background The GeneXpert MTB/RIF assay is a new diagnostic test that depends on a real-time PCR analysis of the sample for diagnosis of tuberculosis (TB) and detection of rifampicin resistance. Aim The aim was to evaluate the role of role of GeneXpert in the diagnosis of sputum-negative pulmonary TB. Patients and methods This study included 30 patients suspected to have TB, with mean age being 45.5±17.7 years. All patients had clinical and radiological signs consistent with TB, positive tuberculin test results, and three negative Ziehl–Neelsen sputum smears. Patients having no or incomplete data were excluded from the study. ResultsThis study included 30 patients suspected to be have TB, comprising 24 (80%) males and six (20%) females. Their age ranged from 18 to 70 years, with a mean age of 45.5±17.7 years. They were selected from the Chest Departments of Bab El-Sha’eria, Al-Hussein University, and El-Abbasia Chest Hospitals in the period from February 2017 to December 2017. All patients have clinical and radiological signs consistent with TB, positive tuberculin test results, and three negative Ziehl–Neelsen sputum smears. Our study showed that GeneXpert was positive in 11 (36.7%) patients and negative in 19 (63.3%) patients. Conclusion The GeneXpert assay can be used as a gold standard to diagnose TB. As it is sensitive and specific for diagnosing smear-negative pulmonary TB, the assay is faster than culture.
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ORIGINAL ARTICLE: BRONCHIAL ASTHMA
	Electronic cigarettes: not an advantageous alternative to conventional smoking in asthma	p. 427
	Heba H AboElNaga DOI:10.4103/ejcdt.ejcdt_83_18   Background Electronic cigarettes (e-cigarettes) have become increasingly popular as an alternative to cigarette smoking, but little is known about their potential adverse effects on airway inflammatory cells and lung function.Objectives This study aimed to differentiate among nonsmoker asthmatics, asthmatics smokers who use conventional cigarettes, and asthmatics smokers who consume e-cigarettes regarding asthma control test, lung function, blood eosinophils, and airway immunoinflammatory phenotype. Patients and methods A total of 130 asthmatic patients were recruited from the Outpatient Clinic of Chest Department of the October 6 University Hospital. Participating individuals were classified into three main categories: nonsmokers, current conventional cigarette smokers, and e-cigarette smokers. All included participants underwent both spirometry and differential cell count in their induced sputum. A venous blood sample was withdrawn for eosinophil counts, which were obtained from the automated complete blood counts. Results There were significant differences between the nonsmoker group and both conventional and e-cigarette smoker groups regarding spirometry and distribution of sputum cell subtypes. Conclusion This study deduced that asthmatic smoker patients who smoke e-cigarettes develop mixed sputum subtype, with no disparity with conventional smokers regarding the pulmonary function and asthma control. These data challenge the concept that e-cigarettes are a healthier alternative to conventional cigarettes.
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ORIGINAL ARTICLE: LUNG CANCER
	Pulmonary complication of chemotherapy and radiotherapy in patients with lung cancer: a prospective cohort study	p. 433
	Ahmed AbdelRahman, Rana El-Helbawy, Maha Youssef, Hager Abdel Megid Alagizy, Mustafa Abu-Shady DOI:10.4103/ejcdt.ejcdt_42_17   Background Lung cancer is a leading cause of cancer-related death worldwide. The main lines of treatment of lung cancer are chemotherapy, radiotherapy, and surgery. Objective The aim was to identify pulmonary complications following the administration of chemotherapy and radiotherapy in the treatment of lung cancer.Patients and methods This prospective cohort study included 50 adult patients with diagnosed lung cancers, who were scheduled to undergo chemotherapy and/or radiotherapy. Patients were divided into three groups (group 1: patients with no complications at the end of follow-up, group 2: patients who developed pulmonary complications, and group 3: patients with extrapulmonary complications). Baseline and post-treatment laboratories and radiological data were recorded for all patients during the 6-month follow-up period. Results A 64% of participants were men, and the mean age was 54.2±10.2 years. Interestingly, 54% of the included participants were never smokers and 8% were ex-smokers. The majority of patients (80%) received either chemotherapy or radiotherapy. The most commonly administrated chemotherapy was gemcitabine carboplatin. By the end of follow-up, 28% of the patients developed pulmonary infection, whereas 10% of the patients developed pulmonary embolism (one patient developed pulmonary embolism with respiratory failure). The mortality rate was 18%. There was a statistically significant difference between the complicated and noncomplicated groups in terms of basic characteristics pulmonary function test (P<0.05). Conclusion In conclusion, the incidence of pulmonary complications among adult patients with lung cancer who receive different modalities is high. The most commonly encountered complications are pulmonary infections and pulmonary embolism.
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ORIGINAL ARTICLES: PLEURAL DISEASES
	Diagnostic value of immunopathology in malignant pleural tumors	p. 440
	Taghreed S Farag, Abeer S Farag, Hanan A Oreiby DOI:10.4103/ejcdt.ejcdt_75_18   Background Immunohistochemistry (IHC) plays a basic role in the diagnosis and differentiation of malignant pleural tumors (MPT). Objective To recognize histological types of MPT to enhance selection of IHC markers for final diagnosis and to simplify the panel of antibodies required. Patients and methods This study was conducted on 30 patients with histopathologically confirmed MPT of 73 patients having clinical and/or radiological evidences of pleural effusion with or without pleural-based masses. Pleural fluid cytology and histopathological examinations for pleural biopsy were done. IHC was performed for histopathologically confirmed MPT. Two mesothelial positive markers and two carcinoma positive markers were used to differentiate malignant mesothelioma (MM) from metastatic carcinoma. Results Histopathological examination demonstrated that MM with mixed pattern was suspected in 16.7%, metastatic adenocarcinoma with malignant glandular component was suspected in 50%, and undifferentiated carcinoma in 33.3%, with no sarcoma or sarcoma-like pattern. By IHC, MM was proved in 26.7% and metastatic carcinoma was proved in 73.3% of cases. Calretinin had 90.9% specificity and 87.5% sensitivity for MM. Hector Battifora mesothelial-1 had 100% sensitivity for MM, but it was also positive in 54.5% of metastatic carcinoma. Carcinoembryonic antigen had 100% specificity for metastatic adenocarcinoma. Ber-EP4 has no significant value to differentiate metastatic carcinoma from mesothelioma.Conclusion Although there was a difference in the sensitivity and specificity of IHC markers in differentiating MM and metastatic carcinoma, the panel of three markers can identify tumor type with epithelioid cell pattern with a high degree of confidence. Accurate clinical history and radiological examination provide guidance.
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ORIGINAL ARTICLES: SLEEP DISORDERS
	The effect of treatment with continuous positive airway pressure on carotid artery intima–media thickness and the correlation between obstructive sleep apnea severity and carotid wall thickness in OSAS patients	p. 451
	El-Azem I Amal Abd, Mohamed M.N AboZaid, Hosam M Attia DOI:10.4103/ejcdt.ejcdt_41_18   Background Obstructive sleep apnea (OSA) is associated with increased carotid intima–media thickness (CIMT), which is an early marker of atherosclerosis. Continuous positive airway pressure (CPAP) is the first-line of treatment for OSA. A prospective study was performed to determine whether CPAP therapy could decrease CIMT. Objective To estimate the effect of CPAP treatment and also the degree of OSA severity on CIMT in patients with OSA. Patients and methods A prospective study was conducted on 50 patients who were newly diagnosed with OSA. The patients were divided into two groups: the CPAP group who were compliant on using CPAP device and the conservative treatment (CT) group who refused to use the CPAP device and remained only on conservative measures. CIMT was measured (with B-mode ultrasound) for both groups at the start of the study and after 6 months. Result We have 27 and 23 OSA patients who received the CPAP device and CT, respectively. We found no significant differences between both groups regarding the baseline parameters. Also at the start of the study there were no significant differences regarding the polysomnographic (PSG) parameters and ultrasonographic measurements of CIMT. CIMT was found to be high in OSA patients. After 6 months of study, there were significant improvement in PSG parameters and a significant reduction in CIMT in the CPAP group while in the CT group the CIMT increased and the PSG parameters became worse. Conclusion Patients with OSA had an increased CIMT suggestive of an atherosclerotic process. The thickness was higher in severe OSA. CPAP treatment was found to decrease CIMT significantly in OSA patients with CPAP compliance.
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ORIGINAL ARTICLE: PUMONARY INFECTION
	Association between passive smoking and community-acquired pneumonia among the adult population	p. 457
	Ibrahim A Dwedar, Mohamed A El Sayed DOI:10.4103/ejcdt.ejcdt_35_18   Introduction Exposure to passive smoking emerges as a significant risk for developing respiratory infections especially community-acquired pneumonia (CAP). This study was designed to assess the effect of passive smoking exposure on developing CAP. Patients and methods A case–control study including 40 patients presented with CAP were divided into two groups according to being exposed or not exposed to passive smoking in their home environment. They were assessed clinically and their length of hospital stay and duration of possible ICU admission were estimated. Mechanical ventilation and mortality risk were also secondary endpoints in this study. Results Age and sex among both groups did not show significant differences. Length of hospital stay and duration of ICU admission were significantly higher in passive smoker patients. Patients aged 60 years old or higher were at more increased risk of developing CAP. In addition, patients exposed to two or more smokers in their homes had a higher risk of having CAP. Conclusion Passive smoking exposure increases risk of developing CAP. The risk is increased significantly in patients of 60 years old or over as well as in patients exposed to two or more smokers in their home environment.
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ORIGINAL ARTICLES: MISCELLANEOUS
	Prevalence and impact of anemia in patients with chronic respiratory diseases	p. 461
	Ali Omar Abdelaziz, El-Ham Abd El-Hady Abd El-Ghany, Omnia Makram, Mohammed Omar Abd El-Aziz, Mohamad El-Hoseany Magdy, Esmat El-Sharkawy DOI:10.4103/ejcdt.ejcdt_39_17   Objective This study aimed to evaluate the prevalence and type of anemia in patients with different chronic pulmonary diseases and its impact on the quality of life. Patients and methods The current study is a prospective observational study that was conducted at Chest Department, Minia University Hospital during the period from November 2015 to January 2017. A total of 247 patients with chronic pulmonary diseases (97 chronic obstructive pulmonary disease, 45 idiopathic pulmonary fibrosis, 80 bronchial asthma, 25 bronchiectasis) were included in our study. For all included patients the following were done,full history taking, assessment of the grade of dyspnea using modified medical research council dyspnea scale, assessment of BMI, chest ꞉ X ray (CXR), ECG and when indicated echocardiography, pulmonary functions tests, routine laboratory investigations, including complete blood count, liver function test, renal function test, serum electrolytes, erythrocyte sedimentation rate, C-reactive protein, measurement of arterial blood gases, measurements of serum erythropoietin, iron and total iron binding capacity, St George’s Respiratory Questionnaire was used for all patients to assess the health-related quality of life. Results Anemia occurs in 36.4% of all patients. It occurs in 46.4% of chronic obstructive pulmonary disease patients, 37.8% of idiopathic pulmonary fibrosis patients, and 12.5% of patients with asthma and in 68% of patients with bronchiectasis. Normocytic normochromic anemia was the predominant type of anemia in the studied patients. There was a significant difference between anemic patients and patients with normal hemoglobin (Hb) with respect to smoking index, comorbidities, forced expiratory volume 1, forced vital capacity, and PO2. C-reactive protein and erythrocyte sedimentation rate were significantly higher in the anemic group. Serum iron and total iron binding capacity were significantly lower in the anemic patients, whereas erythropoietin was significantly lower in patients with normal Hb. Anemic patients had significantly higher medical research council dyspnea scale and number of exacerbation than patients with normal Hb. Anemic patients had significantly higher score in all the components of St George’s Respiratory Questionnaire. Conclusion Anemia is commonly associated with comorbidity in patients with chronic pulmonary diseases. The presence of anemia has a negative impact on the patient’s quality of life. Anemia was significantly associated with; the severity of impairment of lung functions, level of systemic inflammatory markers, presence of other comorbidities, and the smoking index. It was also associated with increased severity of dyspnea and frequent exacerbations.
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CASE REPORTS
	Massive pulmonary embolism as first presentation of primary antiphospholipid syndrome: a case report and literature review	p. 471
	Mostafa M.Y Bakeer, Abd El-Fattah A Touman DOI:10.4103/ejcdt.ejcdt_30_18   Large pulmonary embolisms (PE) have the potential to cause obstructive shock, a hemodynamic state that is usually fatal without prompt medical interventions. A search for the underlying causes in such presentation is usually postponed to a later stage, as the cause is either not obvious nor does it have immediate management implications. Frequently, history and examination are sufficient to identify the precipitating factors for PE; however, many cases remain idiopathic even after exhausting the investigation resources. Primary antiphospholipid syndrome is a systemic autoimmune disorder that is known to cause a hypercoagulable state. Early diagnosis of antiphospholipid syndrome might have therapeutic implications on the short-term as well as long-term patient management; thus, we suggest that it should be included in the workup of cases presenting with massive PE.
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	Digital clubbing: the bad omen that endures	p. 475
	Mahmoud Reda, Maged Hassan, Rana Rizk DOI:10.4103/ejcdt.ejcdt_53_18   Digital clubbing is an important clinical sign that is usually associated with serious condition. Most of the diseases causing clubbing are thoracic, but it is sometimes seen in gastrointestinal or endocrinal disorders. In heavy smokers, thoracic malignancy is the most important entity that needs to be ruled out in patients who exhibit clubbing. Here, we will present a case in which a male heavy smoker who exhibited acute exacerbation of chronic obstructive pulmonary disease and had clubbing, neither had any malignancy on chest computed tomography nor any other medical explanation for the sign. Six months after the first presentation, the patient developed pleural effusion that turned out to be mesothelioma.
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LETTER TO EDITOR: TUBERCULOSIS
	The necessity of conducting studies for mycobacterial interspersed repetitive-unit-variable-number tandem repeat typing of Mycobacterium tuberculosis	p. 479
	Masoud Keikha DOI:10.4103/ejcdt.ejcdt_99_18
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