Objective sputum colour assessment and clinical outcomes in bronchiectasis: data from the European Bronchiectasis Registry (EMBARC).

BACKGROUND: A validated 4-point sputum colour chart can be used to objectively evaluate the levels of airway inflammation in bronchiectasis patients. In the European Bronchiectasis Registry (EMBARC), we tested whether sputum colour would be associated with disease severity and clinical outcomes. METHODS: We used a prospective, observational registry of adults with bronchiectasis conducted in 31 countries. Patients who did not produce spontaneous sputum were excluded from the analysis. The Murray sputum colour chart was used at baseline and at follow-up visits. Key outcomes were frequency of exacerbations, hospitalisations for severe exacerbations and mortality during up to 5-year follow-up. RESULTS: 13 484 patients were included in the analysis. More purulent sputum was associated with lower forced expiratory volume in 1 s (FEV1), worse quality of life, greater bacterial infection and a higher bronchiectasis severity index. Sputum colour was strongly associated with the risk of future exacerbations during follow-up. Compared to patients with mucoid sputum (reference group), patients with mucopurulent sputum experienced significantly more exacerbations (incident rate ratio (IRR) 1.29, 95% CI 1.22-1.38; p<0.0001), while the rates were even higher for patients with purulent (IRR 1.55, 95% CI 1.44-1.67; p<0.0001) and severely purulent sputum (IRR 1.91, 95% CI 1.52-2.39; p<0.0001). Hospitalisations for severe exacerbations were also associated with increasing sputum colour with rate ratios, compared to patients with mucoid sputum, of 1.41 (95% CI 1.29-1.56; p<0.0001), 1.98 (95% CI 1.77-2.21; p<0.0001) and 3.05 (95% CI 2.25-4.14; p<0.0001) for mucopurulent, purulent and severely purulent sputum, respectively. Mortality was significantly increased with increasing sputum purulence, hazard ratio 1.12 (95% CI 1.01-1.24; p=0.027), for each increment in sputum purulence. CONCLUSION: Sputum colour is a simple marker of disease severity and future risk of exacerbations, severe exacerbations and mortality in patients with bronchiectasis.

Bronchodilator reversibility testing in long-term cough and dyspnea after Covid-19 viral infection: a trigger for asthma?

Objective: This study aims to investigate the presence of underlying chronic airway disease in individuals with chronic cough and dyspnea lasting longer than eight weeks and who had previously Coronavirus disease 2019 (COVID-19) and had no known lung disease.Methods: A total of 151 patients admitted to the respiratory diseases outpatient room with the complaint of cough and/or dyspnea that persisted for at least eight weeks following COVID-19 infection were accrued to the study. Demographic characteristics, smoking history, the severity of lung involvement on chest computed tomography in the acute phase of Covid-19 infection, and bronchodilator reversibility test results were recorded. Smoking history and forced expiratory volume in the first second (FEV1) were compared.Results: FEV1 increase ≥ 200 ml was observed in 40 (26.5%) patients. In 24 (15.9%) patients, an increase in FEV1 was found to be 200 ml and above, and the percentage of FEV1 was 12% or more. While 14 (9.3%) patients were diagnosed with asthma, 13 (8.6%) patients were diagnosed with nonreversible airflow obstruction (NRAO), and 1 (0.7%) patient was diagnosed with chronic obstructive pulmonary disease (COPD).Conclusions: COVID-19 infection may play a vital role in initiating asthma pathogenesis. It should be kept in mind that viral infection-related asthma may be the underlying cause of prolonged cough and dyspnea after COVID-19 infection.

Does Mild Coronavirus Disease 2019 Pneumonia in Healthy Adults Cause Permanent Small Airway Injury?

OBJECTIVES: Impulse oscillometry (IOS) is a type of oscillation technique that measures the input impedance (Z) of the respiratory system and can be used to detect pathological changes in the small airways at an early stage. Although coronavirus disease 2019 (COVID-19) affects the vascular and parenchymal structures in the lung, chronic postinfection coughs also may be attributed to small airway pathologies. Our research aimed to use IOS for the assessment of the presence of small airway resistance (R) in patients who have had COVID-19. METHODS: Thirty-eight patients with past COVID-19 infections and without any presence or medical treatment of an airway disease who presented to the post-COVID outpatient clinic with coughing symptoms were included in the study. The control group consisted of 17 patients with no past COVID-19 infection and without an airway disease. IOS and spirometry were performed twice in the case group, at 3 and 6 months after COVID-19. RESULTS: The mean age of the case group was 44.7 ± 12.3 years, whereas the mean age of the control group was 49.4 ± 11.8 years. The case group consisted of 38 patients, whereas 17 patients constituted the control group. No statistically significant difference was found between the two groups in the first and second test measurements, performed 3 months apart (P > 0.05). CONCLUSIONS: The fact that there was no difference between respiratory system impedance, airway resistance, and spirometry values between groups with and without past COVID-19 infections supported the hypothesis that small airways were not affected 3 months after COVID-19.

Adherence, quality of life, and satisfaction with conventional fix combined therapy versus maintenance and reliever therapy in patients with asthma after inhaler training.

OBJECTIVE: Treatment adherence, asthma control, inhaler satisfaction, and quality of life of patients with asthma were investigated to examine whether there were any differences between conventional fixed combined therapy and maintenance and reliever therapy after inhaler education. METHODS: Cross-sectional observational follow-up of 120 patients with asthma receiving third- and fourth-step treatment was completed at zero, three, and six months. Fifty-eight patients received long-acting beta-agonists or inhaler corticosteroids (ICS) as maintenance therapy and short-acting beta-agonists (SABA) as reliever therapy (CONV) with Diskus and Ellipta devices. Sixty-two patients received ICS/formoterol as maintenance and reliever therapy (MART) with metered-dose inhaler and Turbuhaler devices. The asthma control test (ACT), feeling of satisfaction with the inhaler (FSI-10) questionnaire, Morisky Green Levine (MGL) scale, and quality of life questionnaire (AQLQ) were evaluated at each visit. RESULTS: Significant improvement was observed in the ACT, AQLQ, FSI-10, MGL scales, and inhaler technique in both groups over time (p < 0.05). There was no difference in the MGL scale between the groups at all visits. Nonadherence was highest in the Diskus device group (55%) and lowest in the Ellipta device group at the first visit (25%). While 36% of the patients had low adherence at the first visit, this decreased to 12% by the last visit. A significant correlation was found between ACT and MGL at all visits (p < 0.001). CONCLUSION: Asthma control, adherence, inhaler satisfaction, and quality of life improved equally with regular follow-up and standard inhaler education in the CONV and MART groups.

Inhaled corticosteroids' effects on biomarkers in exhaled breath condensate and blood in patients newly diagnosed with asthma who smoke.

OBJECTIVE: Exposure to cigarette smoke complicates the treatment and management of asthma through a variety of inflammatory effects. This study aimed to investigate the differences between newly diagnosed cases of asthma in smokers and nonsmokers in terms of localized and systemic biomarkers following treatment with inhaled corticosteroids (ICS) or ICS in combination with a long-acting ß2 agonist (LABA). METHODS: Specimens of exhaled breath condensate (EBC) from newly diagnosed patients with asthma were used to quantify inflammation in the airways, while blood samples were used to assess systemic inflammation. In both samples, the levels of IL-6, LTB4, LTD4, and 8-isoprostane were measured and these were repeated after 3 months of treatment with ICS or ICS + LABA. RESULTS: Of the 20 patients, 10 (50%) were nonsmokers with asthma (NSA) and 10 (50%) smokers with asthma (SA). There was no statistically significant difference in the blood or EBC levels of IL-6, LTB4, LTD4, or 8-isoprostane between the groups prior to treatment. Only the decrease in 8-isoprostane level in the EBC samples was found to be significantly greater in the NSA group after treatment (for smokers, the change was 2.91 ± 23.22, while for nonsmokers it was -22.72 ± 33.12, p = 0.022). Post-treatment asthma control was significantly better in the NSA group (p = 0.033). CONCLUSION: Monitoring the alterations in 8-isoprostane levels in EBC in patients with asthma who smoke may be helpful in deciding on therapeutic management and switching treatments. Asthma control was better in nonsmokers than in smokers.

The frequency of obstructive sleep apnea in patients with primary Sjogren's syndrome.

INTRODUCTION: There is a lack of information about the frequency of obstructive sleep apnea (OSA) in primary Sjogren's syndrome (pSS). Using all-night polysomnography (PSG), this study aimed to investigate the frequency of OSA in pSS and the factors affecting the frequency of OSA in this condition.  METHODS: Consecutive patients with pSS who presented to the Collagen Tissue Diseases follow-up polyclinic of the Department of Chest Diseases between 1 April 2019 and 31 December, 2020, were included in the study. Demographic characteristics, chronic diseases, smoking history in pack-years, anthropometric data, Epworth Sleepiness Scale score, pulmonary function test parameters, current thorax computed tomography findings, and PSG data were recorded. The control group was created by the retrospective screening of patients admitted to the sleep polyclinic and who underwent PSG but did not have pSS. RESULTS: OSA was detected in 37 (84%) of 44 patients with pSS who underwent PSG. Of 37 patients with OSA, 25 (68%) had moderate or severe OSA. Snoring and witnessed apneas, REM%, snoring index, and maximum apnea and maximum hypopnea duration were statistically significantly lower in the pSS group compared with the control group (p < 0.001, p = 0.003, p = 0.025, p = 0.001, p = 0.028, and p = 0.035, respectively). CONCLUSION: The frequency of OSA in patients with pSS was 84%, with a decrease in REM%. Although a correlation between symptoms suggesting OSA and the presence of radiological lung involvement, spirometry, and DLCO values with OSA could not be demonstrated, physicians are recommended to be attentive for the presence of OSA in all patients with pSS and to investigate OSA using PSG.

Screening for latent tuberculosis before starting TNF-alpha inhibitors in a population with high BCG vaccination rates.

It is assumed that in candidates for TNF-alpha inhibitor (TNFi) treatment, tuberculin skin test (TST) may be unreliable, since BCG vaccination causes false positive and drugs cause false negative results, favoring the use of Quantiferon or T-spot assays. However, these tests may not be readily available in all parts of the world. We aimed to determine the reliability of TST with respect to BCG vaccination and drugs in candidates for TNFi treatment, and how isoniazid is tolerated, assuming that the use of TST would result in increased isoniazid use. We included 1031 adult patients who were prescribed a TNFi for the first time. We analysed the association of BCG and drugs with TST and Quantiferon results, the determinants of a positive TST, and evaluated the tolerability of isoniazid. BCG vaccination and male sex were associated with positive TST (OR 3.56, 95% CI 1.98-6.41 and OR 2.54, 95% CI 1.75-3.68, respectively), while prednisolone and azathioprine were associated with negative TST (OR 0.63, 95% CI 0.43-0.91 and OR 0.40, 95% CI 0.11-0.76). Isoniazid was prescribed to 684 (66.3%) patients and had to be discontinued in 12.2% of these before 9 months, most commonly due to hepatotoxicity (44%). One patient developed tuberculosis despite isoniazid use. BCG vaccination may be associated with false positive TST, despite a long time since vaccination in candidates for TNFi treatment. Prednisolone and azathioprine use were associated with negative TST. Despite the high frequency of isoniazid use associated with using TST instead of QTF, isoniazid was generally well tolerated.

Clinical outcomes of geriatric patients with COVID-19: review of one-year data.

AIMS: In this study, we aimed to reveal mortality rates and factors affecting survival in geriatric patients infected with COVID-19. METHODS: This is a retrospective study of 873 geriatric patients with COVID-19 who were hospitalized between March 11, 2020 and March 11, 2021. Demographic, clinical, laboratory data, and treatment options were obtained from electronic medical records. Multivariate logistic regression was used to explore the risk factors for in-hospital death. RESULTS: During the specified period, 643 patients were discharged, and 230 patients died in the hospital. The mean age was 75.08 ± 7.39 years (mean ± SD) and 51.8% were males. We found that older age (≥ 85), polypharmacy, dyspnea, abnormal thorax computed tomography (CT), lower doses of anticoagulation, and high values of white blood cell, aspartate aminotransferase, C-reactive protein, lactate dehydrogenase, ferritin were associated with a significant increase in mortality (P < 0.001 for all). Although all of these values were significant in multivariate logistic regression analysis, the most important ones were dyspnea (Odds ratio (OR) 57.916, 95% confidence interval (CI) 23.439-143.104, P < 0.001), polypharmacy (OR 6.782, 95% CI 3.082-14.927, P < 0.001), and thorax CT classification (typical; OR 9.633, 95% CI 2.511-37.122, P < 0.001). CONCLUSION: Older age, polypharmacy, dyspnea, and abnormal thorax CT were the most significant mortality criteria and in addition appropriate anticoagulant use was associated with reduced mortality. Identifying the risk factors to predict mortality in older adults with COVID-19 is important to treat future cases successfully.

Annual FEV1 Loss in Patients with Noncystic Fibrosis Bronchiectasis and Affecting Factors.

OBJECTIVES: Bronchiectasis is a chronic respiratory disease characterized by sputum production, cough, and several bronchial infections. Lung function is an important parameter to evaluate and study in patients with bronchiectasis. This study aimed to evaluate the annual changes in forced expiratory volume in one second (FEV1) and related factors in patients with with noncystic fibrosis bronchiectasis. METHODS: A total of 529 patients who were diagnosed as having bronchiectasis using computed tomography and followed at the bronchiectasis unit of the Cerrahpasa Medical Faculty at Istanbul University between 1996 and 2018 were included in this retrospective study. A total of 153 patients were included in the study. RESULTS: The mean age of the patients was 58.6 ± 16.8 years and 61% (n = 93) were female. The annual change of FEV1 and forced vital capacity was -39 ± 82 (minimum: -585, maximum: 355, median: -26) mL and - 44 ± 91 (minimum: -517, maximum: 303, median: -31) mL, respectively. There was no correlation in FEV1 decline between those with and without Pseudomonas colonization (P = 0.65). No correlation was found between the etiologic factors and the decline of FEV1. A correlation existed only between the first FEV1 and the decline of FEV1 (for the first FEV1%, P = 0.038 [R = -0.17]; for the first FEV1 [mL] P = 0.026 [R = -0.18]). CONCLUSIONS: An annual mean FEV1 loss of 39 mL was found in adult patients with noncystic fibrosis bronchiectasis. The annual mean FEV1 decline was found to be associated with the baseline FEV1 value. Physicians should exercise caution in this regard in patients with bronchiectasis with low FEV1 values.

Induced sputum eosinophilia and pulmonary function tests in ex-smokers with asthma controlled with an inhaled steroid and long-acting beta-agonist therapy.

Introduction: This study aims to investigate the relationship between induced sputum eosinophilia and pulmonary functions in ex-smoker asthma patients controlled with an ICS/LABA therapy. Materials and Methods: Asthma patients who are known to use ICS/LABA regularly for at least three months, without an attack in the last month, quit smoking (5-20 pack-years) and have asthma under control (ACT> 20), and concurrent with induced sputum cytology who had spirometry and lung volume measurements were included in the study. Cytology results, induced sputum eosinophil and neutrophil counts, FEV1 (L), FEV1 (%), FVC (L), FVC (%), RV (L), RV (%) and RV/TLC (%) values of all patients were recorded. The relationship between sputum neutrophil and eosinophil count and pulmonary function test parameters was evaluated. Result: Seventeen (68%) of the patients were female, eight (32%) were male, and the mean age was 49.7 ± 13.6 years. The mean sputum eosinophil percentage was 9.4 ± 16.7, and the neutrophil percentage was 71.4 ± 20.5. A positive correlation was found between induced sputum eosinophil percentage values and FEV1 (L) (r= +0.472; p= 0.01) and FVC (L) (r= +0.502; p= 0.01). No correlation was found between the FEV1/FVC%, FEV1%, FVC%, RV (L), RV%, and RV/TLC% values and the percentage of induced sputum eosinophils (p> 0.05). Conclusions: It was observed that controlled asthmatic patients with induced sputum eosinophilia treated with ICS/LABA and who quit smoking had high FVC (L) and FEV1 (L) levels.

An easy-to-use nomogram for predicting in-hospital mortality risk in COVID-19: a retrospective cohort study in a university hospital.

BACKGROUND: One-fifth of COVID-19 patients are seriously and critically ill cases and have a worse prognosis than non-severe cases. Although there is no specific treatment available for COVID-19, early recognition and supportive treatment may reduce the mortality. The aim of this study is to develop a functional nomogram that can be used by clinicians to estimate the risk of in-hospital mortality in patients hospitalized and treated for COVID-19 disease, and to compare the accuracy of model predictions with previous nomograms. METHODS: This retrospective study enrolled 709 patients who were over 18 years old and received inpatient treatment for COVID-19 disease. Multivariable Logistic Regression analysis was performed to assess the possible predictors of a fatal outcome. A nomogram was developed with the possible predictors and total point were calculated. RESULTS: Of the 709 patients treated for COVID-19, 75 (11%) died and 634 survived. The elder age, certain comorbidities (cancer, heart failure, chronic renal failure), dyspnea, lower levels of oxygen saturation and hematocrit, higher levels of C-reactive protein, aspartate aminotransferase and ferritin were independent risk factors for mortality. The prediction ability of total points was excellent (Area Under Curve = 0.922). CONCLUSIONS: The nomogram developed in this study can be used by clinicians as a practical and effective tool in mortality risk estimation. So that with early diagnosis and intervention mortality in COVID-19 patients may be reduced.

Tocilizumab in COVID-19: The Cerrahpasa-PREDICT score.

BACKGROUND: Cytokine release syndrome (CRS), characterized by overproduction of proinflammatory cytokines in the course of severe coronavirus disease 2019 (COVID-19), has been suggested as the major cause of mortality. Tocilizumab, a recombinant humanized monoclonal antibody against human IL-6 receptor, poses a therapeutic option for the treatment of CRS leading to severe acute respiratory syndrome in coronavirus-2 (SARS-CoV-2) infection. METHODS: We performed a single-center retrospective study to reveal the outcome of COVID-19 patients on tocilizumab and proposed "the Cerrahpasa-PREDICT score", a new clinical scoring system using clinical and laboratory parameters that would help predicting the 28-day mortality of COVID-19 patients receiving tocilizumab. RESULTS: Eighty-seven patients (median age: 59 years) were included of whom 75.8% were male. Tocilizumab use significantly improved clinical and laboratory parameters. The 28-day mortality rate on tocilizumab was 16.1%. The Cerrahpasa-PREDICT score, consisting of platelet counts, procalcitonin, D-dimer levels, SO2R and the time from symptom onset to tocilizumab administration had a positive predictive value of 94.5% and negative predictive value of 92.9% for anticipating 28-day mortality. CONCLUSIONS: Severe COVID-19 should closely be monitored for the signs of hyperinflammation. We showed that administration of tocilizumab early in the course of the disease (prior to ICU admission) resulted in a favorable outcome. Close monitoring usually aids identifying patients who would benefit from tocilizumab. In this regard, the Cerrahpasa-PREDICT score might serve as a practical tool for estimating the 28-day mortality in COVID-19 patients who received tocilizumab and would facilitate timely recognition of fatal cases to be evaluated for other therapeutic options.

Increased frequency of obstructive sleep apnea in the patients with systemic sclerosis.

INTRODUCTION: Sleep problems, including obstructive sleep apnea (OSA), profoundly affect quality of life in patients with systemic sclerosis (SSc). This study aimed to determine the prevalence of OSA in patients with SSc and the factors affecting OSA. METHODS: Consecutive patients with SSc lung involvement who were referred to the "Outpatient Service for Interstitial Lung Disease" in our university hospital between 2015 and 2017 were included in the study. All patients completed the Epworth Sleepiness Scale (ESS) and underwent examination including body mass index (BMI), measurement of waist circumference, upper respiratory tract examination, and polysomnography (PSG). Spirometry, carbon monoxide diffusion test (DLCO), and 6-min walking distance were also performed. RESULTS: Of 38 patients, mean age 51.3 ± 11.6 years, 35 were women (92%). Mean apnea-hypopnea index (AHI) was 11 ± 15 (median 5.5) and prevalence of OSA was 58%. Mild OSA was found in 13 (34%) of patients, moderate OSA in 6 (16%), and severe OSA in 3 (8%). Significant relationships were found between age (p = 0.02), waist circumference (p = 0.01), presence of witnessed apneas (p = 0.005), and presence of OSA. CONCLUSIONS: Compared with the general population, the prevalence of OSA is increased in women with SSc. Patients with older age, those with increased waist circumference, and those reporting witnessed apneas should be studied for OSA.

The Relationship between Pre-Pandemic Interferon Gamma Release Assay Test Results and COVID-19 Infection: Potential Prognostic Value of Indeterminate IFN-γ Release Assay Results.

OBJECTIVE: To reveal the relationship between interferon-gamma release assay (IGRA) test (Standard ETB-Feron ELISA (TBF)) results performed within 12 months before the COVID-19 pandemic and the frequency of COVID-19 infections and the severity of COVID-19. METHODS: The retrospective TBF test results and contact information of 684 patients aged over 18 years who underwent TBF testing between March 11th, 2019, and March 10th, 2020, were obtained. Of the 684 patients contacted by phone, 365 agreed to participate in the study and were enrolled. The patients were divided into three groups (TBF test positive, negative, and indeterminate). The data obtained from the questionnaire were compared statistically. RESULTS: According to the TBF test results, positive (n = 51, 14%), negative (n = 286, 78.3%), and indeterminate (n = 28, 7.7%) groups were compared. The frequency of COVID-19 infections in the indeterminate group was found significantly higher than that in the positive and negative groups (p=0.005). When the group with COVID-19 (n = 46, 12.6%) was compared with the group without (n = 319, 87.4%), no difference was found in terms of age, sex, body mass index, smoking history and number of cigarettes smoked, TB history, diabetes mellitus, hypertension, coronary artery disease, and biologic and corticosteroid therapy use. Only the frequency of obstructive pulmonary disease was significantly higher in the group without COVID-19 (p=0.033). CONCLUSION: The frequency of COVID-19 infection was increased in patients with indeterminate TBF test results. Indeterminate TBF test results may be a guide in terms of risk stratification in groups at risk for COVID-19.

Factors affecting mortality in geriatric patients hospitalized with COVID-19

Background/aim: We aimed to investigate the factors affecting the mortality of patients aged 65 years or older who were hospitalized with the diagnosis of new coronavirus pneumonia (COVID-19). Materials and methods: This is a retrospective study of patients 65 years old or older with COVID-19 who were hospitalized in Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty Hospital, between March 11 and May 28, 2020. Demographic, clinical, treatment, and laboratory data were extracted from electronic medical records. We used univariate and multivariate logistic regression methods to explore the risk factors for in-hospital death. Results: A total of 218 patients (112 men, 106 women) were included, of whom 166 were discharged and 52 died in hospital. With univariate analysis, various clinical features and laboratory variables were found to be significantly different (i.e. P < 0.05). In multivariate logistic regression analysis the following were independently associated with mortality: present malignancy [odds ratio (OR) = 4.817, 95% confidence interval (CI) = 1.107­20.958, P: 0.036]; dyspnea (OR = 4.652, 95% CI = 1.473­14.688, P: 0.009); neutrophil/lymphocyte ratio (NLR; OR = 1.097, 95% CI = 1.012­1.188, P: 0.025); the highest values of C-reactive protein (CRP; OR = 1.006, 95% CI = 1.000­1.012, P: 0.049), lactate dehydrogenase (LDH; OR = 1.002, 95% CI = 1.001­1.004, P: 0.003), and creatinine levels (OR = 1.497, 95% CI = 1.126­1.990, P: 0.006); oxygen saturation (SpO2) values on admission (OR = 0.897, 95% CI = 0.811­0.993, P: 0.036); and azithromycin use (OR = 0.239, 95% CI = 0.065­0.874, P: 0.031). Conclusion: The presence of malignancy; symptoms of dyspnea; high NLR; highest CRP, LDH, and creatinine levels; and low SpO2 on admission predicted mortality. On the other hand, azithromycin use was found to be protective against mortality. Knowing the causes predicting mortality will be important to treat future cases more successfully.

The relationship between inflammatory markers and spirometric parameters in ACOS, Asthma, and COPD.

Objective: The inflammatory mechanisms underpinning asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) have not been fully elucidated. Here, we examined the levels of cysteinyl leukotrienes (cys-LTs), prostaglandin D2 (PG-D2), prostaglandin E2 (PG-E2), interleukin 5 (IL-5), and a disintegrin and metalloprotease domain (ADAM 33) in ACOS patients to determine the relationship between levels of these inflammatory markers and pulmonary functions.Methods: Blood samples were obtained from asthma, COPD, and ACOS patients who received combined therapy and were stable for the last month to measure cys-LTs, PG-D2, PG-E2, IL-5, and ADAM33 levels. Differences between groups and their correlations with pulmonary function tests were evaluated.Results: In total, 24 ACOS, 27 asthma, and 35 COPD patients were included. . PG-D2 levels were higher in ACOS (120.9 ± 117.2 ng/L) and asthma (119.6 ± 111.7 ng/L) patients than in COPD (82.6 ± 46.7 ng/L) patients (p = 0.036 and p = 0.038, respectively). In ACOS patients, PG-D2, cys-LTs, and ADAM33 levels were negatively correlated with FEV1/FVC% values (p = 0.021, p = 0.008, and p = 0.028, respectively). In COPD patients, a negative correlation was detected between PG-E2 and FEV1/FVC% (p = 0.007), whereas positive correlations were detected between IL-5 and pulmonary function tests, including FVC, FVC%, FEV1, FEV1%, FEF25-75, and FEF25-75% (p = 0.047, p = 0.005, p = 0.002, p = 0.002, p = 0.010, and p = 0.005, respectively). In asthma patients, cys-LTs levels were negatively correlated with FEV1 and FEF25-75 values (p = 0.045 and p = 0.037, respectively).Conclusions: PG-D2 levels may be a valuable biomarker to differentiate COPD in asthma and ACOS patients.

Re-initiation of biologics after the development of tuberculosis under anti-TNF therapy.

The use of anti-TNF agents is associated with an increased risk of tuberculosis (TB) and anti-TNF agents are stopped when active TB develops. However, discontinuation of treatment can result in flare of the underlying disease. The charts of 22 patients who developed active TB among a cohort of 2754 patients using anti-TNF agents between 2001 and 2013 were reviewed retrospectively. Patients restarting biologics during further follow-up were identified. One patient with miliary TB died within 1 month. A biologic agent was restarted in 16 of the remaining 21 patients (76 %). The most frequently re-initiated biologic agent was etanercept (n = 6) followed by rituximab (n = 5) and interferon-alpha (n = 3). Biologic treatment was re-initiated during anti-TB treatment in four patients and after completing TB treatment in 12 patients. The median follow-up after restarting biologics was 53 (IQR: 40-75) months. TB re-occurred in one patient with Behçet's syndrome, who initially received etanercept due to severe sight-threatening uveitis at the third month of anti-TB treatment followed by canakinumab 15 months later along with methotrexate, cyclosporine and corticosteroids. After a second course of 9 months TB therapy this patient is currently stable on interferon-alpha for 33 months. Restarting of anti-TNF agents and other biologic agents, even during TB treatment, seems to be possible among patients who had previously developed TB under anti-TNF treatment. However, the risk of re-development of TB infection mandates careful follow-up.

The awareness of chest physicians about nutritional assessment in chronic obstructive pulmonary disease.

INTRODUCTION: The number of studies that target nonpharmacologic treatments for chronic obstructive pulmonary disease (COPD) are increasing because no existing pharmacologic treatment modality for COPD leads to significant improvement in lung function.Positive effects can be observed in patients with COPD using nutritional support alone or as an adjunct to exercise. In this study, we aimed to evaluate the awareness of chest physicians about the nutritional state of patients with COPD. MATERIALS AND METHODS: A questionnaire consisting of 15 multiple choice questions was conducted to 121 chest physicians. The questions were formed to evaluate the awareness of chest physicians on the patients' nutritional state and the importance of nutrition in COPD follow-up. RESULT: In total, of the 121 physicians, only 3 (2.5%) reported undertaking routine assessment for nutritional state of patients with COPD. The rates of physicians who routinely questioned patients about weight loss and loss of appetite were 56.2% (n= 68) and 51.2% (n= 62), respectively. Forty-five (37.2%) physicians said that they usually started nutritional support if they detected weight loss in patients with COPD. CONCLUSION: Although there is limited data on the benefits of nutritional supplementation for patients with COPD, some studies have suggested advantages of nutritional support against the progress of COPD. Our study showed that routine screening for malnutrition in patients with COPD is rare among chest physicians and this did not differ according to the hospitals in which they worked or from where they took their residency training. There is a need for further studies emphasizing the importance of nutritional state in the progress of COPD.

Comorbidities and their impact on chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a complex disease that is associated with devastating outcomes resulting from lung involvement and several comorbidities. Comorbidities could impact on symptomology, quality of life, the complications, the management, economic burden and the mortality of the disease. The importance of comorbidities originates from their impact on the outcome of COPD. The most frequent comorbidities in COPD are cardiovascular, endocrinological, musculoskeletal, phycological disorders and lung cancer. Almost 50% of the COPD patients have 3 or more comorbidities. The recent Global Initiative of Obstructive Lung Disease (GOLD) Guideline suggested proactive search and the treatment of the comorbidities. However, there is no certain evidence demonstrating that active treatment of comorbidities improve the outcomes of COPD. However, it is well known that several comorbidities such as cardiovascular disease and lung cancer have greater impact on mortality caused by COPD. Several studies have shown that Charlson Comorbidity index or more recenty COPD Specific Comorbidity Index (COTE) has been found to be related with mortality of COPD. This concise review intended to summarize the most frequent comorbidities in association with their impact on COPD.

Factors affecting the tuberculosis risk in patients receiving anti-tumor necrosis factor-α treatment.

BACKGROUND: Tumor necrosis factor (TNF)-α inhibitors are known to increase the risk of tuberculosis (TB). OBJECTIVES: To examine the factors associated with an increased risk of TB in patients receiving anti-TNF-α treatment (aTNF-α-T). METHOD: Of 3,094 patients who received aTNF-α-T between 2003 and 2013, a total of 1,964 subjects with a follow-up time longer than 6 months were identified and included in this retrospective analysis. Potential risk factors for the development of TB in patients receiving aTNF-α-T were evaluated. RESULTS: Of the 1,964 patients, 1,009 (51%) were male and 955 (49%) were female, with a mean age of 39.7 ± 13.9 years. The primary conditions requiring aTNF-α-T included ankylosing spondylitis (n = 875), rheumatoid arthritis (n = 711), Behçet's disease (n = 83), and others (n = 295). Sixteen patients [8 (50%) males and 8 (50%) females; 5 (31.2%) with pulmonary TB and 11 (68.8%) with extrapulmonary TB] developed TB, with a corresponding TB incidence of 466/100,000. No significant associations were found between age, gender, smoking history, pack-years of smoking, isoniazid (INH) chemoprophylaxis, type of anti-TNF-α agent, use of other immunosuppressive drugs, and the risk of TB (p > 0.05). Multivariate logistic regression analysis showed a significantly higher risk of TB in patients diagnosed with Behçet's disease, and a significantly lower risk of TB in patients with a tuberculin skin test wheal ≥10 mm in diameter (p < 0.05). CONCLUSION: aTNF-α-T is associated with an increased risk of pulmonary or extrapulmonary TB, even when follow-up protocols and INH chemoprophylaxis are implemented, and TB often develops in the later stages of treatment. The risk of TB was higher in patients with Behçet's disease and lower in patients who had a strong tuberculin skin test reaction.