Uric acid as a prognostic predictor in COVID-19.

Objective: The purpose of our study was to investigate the incidence and prognostic significance of baseline and control uric acid values in COVID-19. Methods: The study population included patients admitted with the diagnosis of SARS-CoV-2 between March 2020 and March 2021. The demographic data, clinical, laboratory, and radiological findings were recorded. Uric acid levels were measured at the time of admission for 498 patients and at the most severe period of the disease in 143 patients. Length of hospital stay, need for admission to intensive care unit, the course, and outcomes during hospitalization were recorded. Results: The mean age of 261 male and 207 female patients was 62.7(21-95) years. At the time of admission, 21 patients had hypouricemia and 170 had hyperuricemia. The need for ICU was 47.6% in the hypouricemic, 19.2% in the normouricemic, and 21.2% in the hyperuricemic groups. The mean uric acid level was 5.24±2.54 mg/dl in patients who required ICU admission and 5.18±1.98 mg/dl in patients who were discharged from the ward. The difference was not statistically significant. The mean uric acid level was not significantly different in the deceased and survivors. In 143 subjects, uric acid levels were measured after the progression of COVID-19; 73 of them were admitted to the ICU. The mean uric acid levels were found to be significantly decreased in patients with a negative prognosis. Conclusion: In our study, hypouricemia was not found to be a major feature of SARS-CoV-2 infection. Low baseline uric acid levels were associated with increased ICU admission. The decline in uric acid levels during hospital stay predicted poor prognosis, as well.

Comparative Analysis of Three Different Drug Distribution Schemes for Smoking Cessation.

OBJECTIVE: This study aimed to compare the success rate of 3 different drug prescription policies: Free drugs with online system prescription, free drugs with doctor's prescription, and drugs paid for by patients with doctor's prescription. MATERIAL AND METHODS: The effect of 2 different Ministry of Health (MoH) projects with free-of-charge and self-payment pharmacotherapies for smoking cessation were compared. Patients who completed 6 months of pharmacotherapy and follow-up were evaluated. The first period was free-of-charge medication, which was determined by an online system, the following period was the self-payment period, and the third period was free medication, which was prescribed by a doctor. In all the groups, smoking habits in pack years and comorbidities of the patients were recorded, and pulmonary function tests (PFTs) and expiratory carbon dioxide (CO2) measurements were performed. Patients who had an expiratory CO2 level >5 ppm at the control visits were accepted as quitters. RESULTS: A total of 829 patients with 438 patients in the first free-of-charge period (group 1), 111 in the self-payment period (group 2), and 280 in the second free-of-charge period (group 3) were enrolled in the study. Smoking cessation rates were significantly higher in the self-payment medication group (25%) according to the MoH's free-of-charge project groups. There was no difference in smoking cessation rates between the 2 free-of-charge medication project groups (15% in group 1 and 11% of group 3). Among all the patients, we compared 124 patients who quit smoking with 705 patients who did not. The quitters were older, mostly male, and heavier smokers. In addition, the number of patients with chronic obstructive pulmonary disease and obstructive PFT rates were higher among the quitters. Their dependency score, PFTs, and the use of free medication was lower, and treatment duration was longer. Independent factors that increased smoking cessation success were longer treatment duration, lower dependency score, and self-payment of medication. CONCLUSION: Free medications provided via 2 different modalities did not increase the smoking cessation success. Paying for the medication, lower dependency score, and longer treatment duration increased smoking cessation success independently.

Can we enhance compliance to treatment by performing a continuous positive airway pressure trial in obstructive sleep apnea?

BACKGROUND: Although continuous positive airway pressure (CPAP) therapy is the most effective treatment for obstructive sleep apnea (OSA), it is not always easy to gain adherence to therapy. We aimed to evaluate how short-term CPAP application during the daytime before the titration night affects polysomnographic data and CPAP adherence in OSA. METHODS: Patients with moderate to severe OSA for whom CPAP titration was recommended were prospectively randomized to daytime CPAP application (group 1) or usual care (group 2).  For group 1, CPAP was applied for 30-60 min in daytime conditions to acclimate patients to the device. An appointment was then made to perform CPAP titration with PSG. In group 2 (usual care), the first CPAP application was performed on the titration night. PSG recordings and titration night recordings of both groups were compared. All subjects were evaluated 1 month after the initiation of CPAP treatment. RESULTS: Among 246 cases, first night data were similar in both groups. During the titration night, total sleep time, sleep efficiency, and time in stage N3 were significantly higher in patients who underwent the daytime CPAP trial. Adherence to CPAP treatment at first-month follow-up was significantly higher in the group 1 (5.7 ± 1.0 h/night) compared to the group 2 (3.9 ± 1.1 h/night, p < 0.001). CONCLUSION: A short-term daytime CPAP trial in patients before the titration night may provide longer and more efficient sleep on the titration night and better CPAP adherence at one month.

Reversibility of microalbuminuria with continuous positive airway pressure treatment in obstructive sleep apnea syndrome.

INTRODUCTION: Microalbuminuria is an early marker of kidney damage and an early predictor and risk factor for cardiovascular diseases. We aimed to evaluate the association between albuminuria levels in different severity obstructive sleep apnea syndrome (OSAS) cases and to find out the efficacy of CPAP treatment on microalbuminuria. MATERIALS AND METHODS: We conducted a prospective study on subjects who underwent polysomnography. The polysomnographic data were recorded to establish the presence and severity of OSAS. The blood and urine samples were taken both at the time of diagnosis and 3 months after CPAP therapy. The relationship between the severity of OSAS and microalbuminuria and the effect of CPAP treatment on microalbuminuria were evaluated. RESULTS: The study population consisted of 449 subjects. Better compliance to CPAP was associated with significantly reduced levels of microlbuminuria. Urinary albumin/creatinine was increased in severe cases, but the difference was not statistically significant. In the non-compliant group, microalbumin/creatinine ratio was 25.24 prior to initiation of CPAP treatment and 28.36 at the third month control visit (p = 0.25). In the compliant group, microalbumin/creatinine ratio was 49.71 prior to initiation of CPAP treatment and 22.30 at the third month control visit (p = 0.04). CONCLUSION: Our study demonstrated that good compliance to CPAP therapy is associated with a decrease in microalbuminuria. Patients who used CPAP regularly had a significant decline in albumin/creatinine ratio after 3 months of CPAP therapy.

Can We Predict Bleomycin Toxicity with PET-CT?

AIM: Bleomycin is an antitumor antibiotic used successfully to treat a variety of malignancies, predominantly germ cell tumors and Hodgkin's lymphoma (HL). The major limitation of bleomycin therapy is the potential for life-threatening interstitial pulmonary fibrosis. Early identification of asymptomatic patients who may develop toxicity is important. We aimed to evaluate fluorodeoxyglucose positron-emission tomography (FDG-PET/CT) findings to predict bleomycin toxicity (BT) early after chemotherapy with doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) chemotherapy before clinical symptoms and radiological changes occur. MATERIALS AND METHODS: HL patients who were treated with ABVD were evaluated. SUVmax values of lung parenchyma were analyzed in FDG-PET/CT at diagnosis and after 4 cycles of chemotherapy in all patients. At the end of the chemotherapy cycles, lung parenchymal SUVmax values of patients with BT and without BT were compared statistically. RESULTS: Twenty (66.7%) male and 10 (33.3%) female patients with HL were included. Five (16.7%) HL patients developed BT. In 3 HL patients, BT was determined after 5 cycles and in 2 patients, BT was seen after 6 cycles. In all 5 of these patients with BT, FDG uptake in PET-CT was increased after 4 cycles of chemotherapy and BT was predicted before clinical and radiological findings by FDG-PET/CT. After 4 cycles of chemotherapy, lung parenchymal SUVmax of patients with BT (3.24 ± 0.76) was significantly higher than in patients without toxicity (1.84 ± 0.52) (p < 0.001). In patients with BT, a significant increase was established in lung parenchymal SUVmax after 4 cycles of chemotherapy when compared to the time of diagnosis (p = 0.043). CONCLUSION: BT can be fatal. Early detection of BT is essential in clinical practice. FDG-PET/CT can predict BT before clinical and radiological findings occur.

Ultrasonographic evaluation of lung parenchyma involvement in sarcoidosis.

PURPOSE: To use ultrasonography (USG) for the evaluation of lung parenchyma in patients with sarcoidosis, andto compare the USG findings with the results of a high-resolution computerized tomography (HRCT) and pulmonary function test-carbon monoxide diffusion test (PFT-DLCO), which are commonly used methods in the evaluation of parenchymal involvement in sarcoidosis. MATERIAL AND METHODS: Patients with sarcoidosis and healthy controls were enrolled in the study between January 2015 and December 2017. The clinical findings, HRCT and PFT-DLCO results of all subjects were recorded, and USG findings and comet tail artifact (CTA) measurements were recorded by another pulmonologist. The USG, HRCT and SFT-DLCO findings were compared between the two groups. Based on the findings of theclinical-radiologic investigations and PFT-DLCO, as the current gold standard in diagnosis, the sensitivity and specificity of USG in demonstrating lung parenchyma involvement in sarcoidosis patients were estimated. FINDINGS: The sarcoidosis group consisted of 79 patients and the control group included 34 subjects. The mean number of CTAs in the sarcoidosis and control groups was 33.4 and 25, respectively (p=0.001). In the sarcoidosis group, the number of CTAs in patients with DLCO% <80 and ≥80% was 37.4 and 29.7, respectively (p=0.011), and a negative correlation was identified between the number of CTAs and DLCO% (p=0.019 r=-0.267). The mean number of CTAs in patients with and without parenchymal involvement in HRCT was 36 and 25.5, respectively (p=0.001). The number of CTAs in the patients with sarcoidosis with a normal DLCO% value (≥80%) was higher than in the control group (p=0.014). The diagnostic sensitivity and specificity of thoracic USG were found to be 76% and 53%, respectively. CONCLUSION: The number of CTAs in patients with sarcoidosis was higher than that of the healthy controls. The number of CTAs in patients with sarcoidosis with parenchymal involvement in HRCT and/or a low DLCO (<80%) was also elevated. Thoracic USG has a high sensitivity (76%) in demonstrating parenchymal involvement in patients with sarcoidosis.

Can positron emission tomography/computed tomography be predictive of diagnostic success in endobronchial biopsies performed through a fiber-optic bronchoscopy in lung cancer?

PURPOSE: The purpose of this study is to investigate the effect of homogeneous/heterogeneous (necrotic) involvement and maximum standardized uptake value (SUVmax) value of the lesion on positron emission tomography-computed tomography (PET-CT) of patients who underwent fiberoptic bronchoscopy (FOB) for prediagnosis of lung cancer and biopsy for endobronchial lesion on the diagnostic success of biopsy procedure. METHODS: Between January 2014 and December 2016, patients with final diagnosis of pulmonary malignancy as determined by FOB biopsy and patients who failed to be diagnosed by FOB biopsy and diagnosed with pulmonary malignancy by a different diagnostic method were examined. These patients were divided into two groups as those with diagnosis by FOB biopsy (Group 1) and those who failed to be diagnosed by this method and diagnosed with pulmonary malignancy by a different diagnostic method (Group 2). The SUVmax values of the two groups were compared with lesion characteristics of homogeneous, heterogeneous involvement/presence of necrotic component as shown by PET-CT. Group data were assessed by Chi-square test and Mann-Whitney U-test. In all tests, P < 0.05 was considered significant. FINDINGS: A total of 193 participants with a mean age of 61 ± 9.4 were included in the study. There were 128 (66.3%) cases in Group 1 and 65 (33.7%) cases in Group 2. The mean SUVmax value was 16.4 in Group 1 and 15.1 in Group 2. There was no statistically significant difference between the two groups (P = 0.329). Homogeneous involvement was present in 103 (80.3%) cases in Group 1 versus 42 (64.6%) cases in Group 2. In the presence of homogeneous PET-CT involvement, diagnosis rate by biopsy was significantly higher (P = 0.016). CONCLUSION: We concluded that the high SUVmax value of the mass lesion on PET-CT did not increase the diagnostic value of the biopsy procedure in patients prediagnosed with lung cancer and that the diagnostic success of FOB biopsy was poor in cases where PET-CT showed heterogeneous involvement of the mass lesion.

A New Modality for the Diagnosis of Bleomycin-induced Toxicity: Ultrasonography.

OBJECTIVE: To evaluate the role of ultrasonography (USG) in the diagnosis of bleomycin-induced pulmonary toxicity (BT). MATERIAL AND METHODS: The study included patients with suspected BT during treatment with bleomycin due to various oncologic diseases between June 2015 and May 2017. The patients initially underwent clinical and high-resolution computed tomography (HRCT) examinations and pulmonary function tests (PFT)-diffusing capacity of the lung for carbon monoxide (DLCO), followed by registration of USG findings-number of comet tail artifact (CTA) images by a different pulmonologist. We compared the findings from USG, HRCT, and PFT-DLCO tests between BT and non-BT groups. With the diagnosis based on clinical-radiologic and PFT-DLCO assessments taken as the gold standard, we determined the sensitivity and specificity of the USG outcomes for diagnosis of BT. RESULTS: The study included a total of 30 patients. Nine patients were diagnosed as having BT according to their clinical and radiologic findings and PFT-DLCO measurements. The mean number of CTA images was 68.7±22 in patients with BT vs 28.2±9.3 in those without BT (P<.001). The difference in CTA images between the patients with and without ground glass density was statistically significant (28.3±9.5 and 64.6±24.5, respectively, P<.001). In patients with BT, there was a negative correlation between the number of CTAs and DLCO% and FVC% values (P=.004; P=.016). USG had a sensitivity of 100%, and a specificity of 95% diagnosing BT in selected patients. CONCLUSION: In bleomycin-induced toxicity, USG findings are correlated with HRCT and PFT-DLCO findings, with a remarkably increased number of CTAs in BT. Thoracic USG examination is a diagnostic tool with a high sensitivity and specificity for diagnosing BT.

Relationship of asymmetric dimethylarginine levels with disease severity and pulmonary hypertension in chronic obstructive pulmonary disease.

BACKGROUND: Asymmetric dimethylarginine (ADMA) has emerged as a risk marker for many conditions related to pulmonary hypertension (PH); however, little is known about ADMA and symmetric dimethylarginine (SDMA) plasma concentrations in chronic obstructive pulmonary disease (COPD). Our interest centers on the role of ADMA in regulation of endothelial function in COPD and secondary PH. The aim of the present study was to evaluate the serum ADMA, SDMA, and L-arginine concentrations in COPD and its association with PH. METHODS: Patients with diagnosis of COPD underwent pulmonary function tests, echocardiography, and laboratory investigations including ADMA, SDMA, and L-arginine. RESULTS: Serum concentrations of ADMA, SDMA, and L-arginine tend to increase as COPD progresses. Patients with PH had higher concentrations of ADMA, SDMA, and L-arginine compared to cases with normal pulmonary arterial pressure (PAP); the difference was not statistically significant. CONCLUSIONS: Our results show that increased ADMA, SDMA, and L-arginine concentrations are associated with increased PAP measurements in patients with COPD, however, the relationship is not statistically significant.

Vitamin D Deficiency in Patients Referred for Evaluation of Obstructive Sleep Apnea.

STUDY OBJECTIVES: A recent study reported an association between obstructive sleep apnea (OSA) and low vitamin D levels. In this study, we measured vitamin D levels in patients referred for evaluation of suspected OSA and sought to identify associated risk factors for vitamin D deficiency. Our objective was to determine whether evaluations of patients with suspected OSA should include routine screening for vitamin D deficiency. METHODS: Using a cross-sectional study design, we measured vitamin D levels in consecutively enrolled patients referred for an OSA evaluation to Dr. Lutfi Kirdar Kartal Training and Research Hospital in Istanbul, Turkey. We conducted full-night polysomnography and compared vitamin D levels both between patients with OSA and patients without OSA and across the various severity levels of OSA. We evaluated the association between vitamin D levels and various clinical and demographic characteristics, including the apnea-hypopnea index and body mass index. RESULTS: From April 2014 to June 2015, 195 patients were referred for OSA evaluation. Of these, 181 patients (93%) consented to participate and underwent full polysomnography and measurement of vitamin D levels. The mean ± standard deviation age was 49 ± 12 years and body mass index of 31 ± 6 kg/m2. Polysomnography led to the diagnosis of OSA in 162 of the patients (89.5%): 52 (32%) were categorized as having mild OSA, 38 (23.5%) as having moderate OSA, and 72 (44.5%) as having severe OSA. Vitamin D level was 15.5 ± 11.6 ng/mL (95% confidence interval; 13-17 ng/mL) and 134 patients (74%) met the criterion for vitamin D deficiency (< 20 ng/mL). Sex, vitamin D levels, and percentage of patients with vitamin D deficiency were similar in patients with and without OSA (P > .05). Vitamin D levels were similar across OSA severity categories (P = .68). We found no association between vitamin D levels and the apnea-hypopnea index or body mass index. CONCLUSION: A large proportion of patients referred for OSA evaluation had vitamin D deficiency. Vitamin D levels did not differ by OSA diagnosis status or severity. Patients referred for polysomnography should undergo routine screening for vitamin D deficiency as well as clinically indicated treatment to prevent associated comorbidities.

The Effect of Pulmonary Function Testing on the Success of Smoking Cessation.

BACKGROUND: In several studies, low spirometric levels have been shown to increase the success rates of smoking cessation, whereas other studies have indicated that pulmonary function has no effects on quitting smoking. Given the fact that there are contradictory results on this subject, we aimed to investigate the effect of identifying airway obstruction via spirometry and its explanation to subjects on the success rate of smoking cessation in the short term. METHODS: Subjects who were admitted to the smoking cessation out-patient clinic, underwent pulmonary function tests (PFTs) and completed at least 3 months of the cessation program following their admittance were included in the study. At the first interview, all subjects were asked about their comorbid diseases and smoking habits. PFTs were performed. Subjects who had an obstruction on PFT were informed that their condition was smoking-related, and that further deterioration could be prevented following smoking cessation. Then the smoking cessation date was determined together with the subject, and one of the smoking cessation medicines was prescribed. All subjects were given control appointments twice for the first month and once per month for the following 2-month follow-up period. Subjects who had CO levels between 0 and 5 parts per million were considered as non-smokers. RESULTS: The mean age of the 563 subjects was 41.9 ± 12.1 y 340 subjects (60.4%) were male. A total of 162 subjects (28.8%) came to the follow-up visits following the first interview. The success of smoking cessation for 3 months was 11.3% for all subjects and 39.5% for subjects who came to follow-up visits. Of the subjects with obstruction on PFT; 22.8% stopped smoking, whereas 8.4% of the subjects without obstruction did so (P < .001). The percentage of subjects with obstruction on PFT was significantly higher (P < .001) and the FEV1 % (P = .005), FEV1/FVC (P < .001), and forced expiratory flow 25-75% (P = .008) levels were significantly lower in the quitters compared with the non-quitters. Logistic regression analysis showed that age (P = .001) and the presence of obstruction on PFT (P = .029) were independent variables. CONCLUSIONS: Advanced age and the presence of obstruction on PFT increase the success of smoking cessation. Pulmonary function tests should be performed on all patients who apply to smoking cessation out-patient clinics, and patients should be informed about their condition.

Can a Computer-Based Prescription of Free Medication Increase Smoking Cessation Rates Efficiently?

OBJECTIVES: In 2011, in the context of a research project, bupropion and varenicline were distributed to smoking cessation clinics by the Ministry of Health of Turkey to be prescribed free of charge by a computer-based system. In the present study, we compared smoking cessation rates between patients who were prescribed free medications during the period of the project and those who had to pay for their medication. MATERIAL AND METHODS: Six hundred four patients who applied during the project period were given either bupropion or varenicline, which were prescribed using an algorithm-based computer system. Three hundred sixteen patients who applied after that period were prescribed medicines deemed appropriate by the attending physician but had to pay for the medication on their own. Follow-up visits were arranged for one year. Carbon monoxide (CO) levels in the expired air were used as indicators of cessation. RESULTS: A total of 537 patients began treatment, of which 438 (81.6%) applied during the first period (group 1) and 99 (18.4%) applied during the second period (group 2). The mean age and concomitant disease presence were higher in the second-period patients (p< 0.05). Advanced age, comorbidities, pathological findings in spirometry, and chest X-ray were also higher in those who paid for the cost of their treatment (p= 0.009, 0.001, 0.006, 0.001, respectively). Smoking cessation rates were found to be 14.8% and 27.3% after six months (p= 0.008) and 10.7% and 18.2% after one year (p= 0.059), respectively, for group 1 and group 2. Age, dependence score, cigarettes smoked (as pack-years), and percentage of patients who paid for the treatment were found to be significantly higher (p< 0.001, 0.021, 0.018, 0.001, respectively) for those who quit smoking at the end of six months. For the patients who quit smoking at the end of one year, age was found to be significantly higher (p= 0.008), and the number of males was higher, although the difference was not statistically significant (p= 0.05). When logistic regression analysis was applied, age, dependence score, and paid treatment were found to be independent variables (p= 0.002, 0.008, 0.012, respectively) for those who quit smoking at the end of six months. Only age was found to be an independent variable for those who quit smoking at the end of one year (p= 0.029). CONCLUSION: More smokers could receive treatment by the distribution of free drugs. However, quitting rates at the end of six months were higher when patients had to pay for their treatment. On the other hand, quitting rates at the end of one year were not affected by whether the treatment was paid for or free of charge. The most important factor increasing quitting rates at the end of six months and one year was found to be advanced age.

Endobronchial ultrasound-guided transbronchial needle aspiration in diagnosing intrathoracic tuberculous lymphadenitis.

AIMS: Patients with suspected tuberculosis without pulmonary lesions and with intrathoracic lymphadenopathy often pose a diagnostic challenge. The aim of this study was to describe the diagnostic utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in patients with isoleted intrathoracic lymphadenopathy due to tuberculosis (TB). MATERIALS AND METHODS: Cases with tuberculous lymphadenitis (TBLA) as the final diagnosis were analysed among patients in whom EBUS-TBNA had been performed. All patients underwent routine clinical assessment and a CT scan prior to EBUS-TBNA. Demographic data, pathological findings, and microbiological results were recorded. All patients received 6-month antituberculous treatment, followed-up regularly and recovered both on clinical and radiological basis. RESULTS: Forty-four patients were included. EBUS-TBNA diagnosed TB intrathoracic lympadenopathy in 42 (95.4%) patients. In 2 patients, EBUS-TBNA was not able to confirm a diagnosis and additional procedures were required. Cytopathological findings alone revealed TB in 32 (72.7%) patients. One of the patients (2.2%) was smear positive while microbiological investigations provided a positive culture of TB in 22 (50%) patients. TB culture was positive in 10 of 12 patients in whom cytopathologic evaluation was not able to diagnose. Addition of mycobacterium culture to cytopathologic investigation s improved the diagnostic yield from 72.7% to 95.4%. CONCLUSION: EBUS-TBNA is a safe and effective first line investigation for evaluating isolated intrathoracic tuberculous lympadenopathy. Addition of mycobacterium culture to cytopathologic investigation improves the sensitivity of EBUS-TBNA.

Overnight Transcutaneous Carbon Dioxide Monitoring in Eucapnic Patients with Obstructive Sleep Apnea Syndrome.

OBJECTIVES: We monitored increases in CO2 levels during sleep by measuring transcutaneous pCO2 (PtcCO2) to determine its relationship with polysomnographic data in normocapnic patients with obstructive sleep apnea syndrome (OSAS). MATERIAL AND METHODS: Between October 2011 and December 2012, 139 patients underwent PtcCO2 monitoring with polysomnography. All patients were evaluated with arterial blood gas (ABG) measurements and pulmonary function tests (PFTs). We excluded 13 patients with COPD and/or daytime hypercapnia and 29 patients whose PtcCO2 records could not be evaluated. RESULTS: The patients' mean age was 46.8±10.3 years. Fifty-nine patients (60.8%) were male, and 38 (39.2%) patients were female. The mean overnight PtcCO2 was ≤45 mm Hg in 84 (86.6%) patients and >45 mm Hg in 13 (13.4%) patients. In the group with PtcCO2>45 mm Hg, 10 patients had an apnea-hypopnea index (AHI) >15, and 3 patients had an AHI<15, without a statistically significant difference (p=0.078). The mean apnea and apnea/interapnea periods were similar. The mean PtcCO2 values correlated with time spent when the SpO2 was <90% (r=0.220, p<0.031). When we grouped the patients by AHI, 60 (61.8%) patients had an AHI>15 (moderate to severe OSAS), and 37 (37.2%) had an AHI<15 (mild OSAS). Of the former group, 16.7% had a mean PtcCO2 >45 mm Hg, whereas this ratio was 8.1% in the latter group. The difference was not statistically significant (p=0.359). In the group with an AHI>15, the highest PtcCO2 levels were significantly higher (p<0.05). CONCLUSION: We conclude that seemingly eucapnic OSAS patients may experience hypercapnia when sleeping, and PtcCO2 monitoring may be useful in the early diagnosis of hypercapnia.

The effect of obstructive sleep apnea syndrome and snoring severity to intima-media thickening of carotid artery.

INTRODUCTION: Intima-media thickening (IMT), which is the early finding of carotid artery atherosclerosis, has been shown to be associated with obstructive sleep apnea syndrome (OSAS). In our study, we aimed to assess prospectively the effect of severity of OSAS and snoring on carotid artery IMT. METHODS: A total of 102 patients who were admitted to sleep laboratory between May 2011 and May 2012 were included in the study. All patients were examined by polysomnography. Common carotid arteries (CCA) and internal carotid arteries (ICA) were evaluated for IMT by carotid Doppler ultrasonography. RESULTS: The mean age was 45.9 ± 11.1, with 40 (39.2 %) women and 62 (60.8 %) men. Of 88 OSAS patients who had an apnea-hypopnea index (AHI) of >5, 33 (37.5 %) had mild, 20 (22.7 %) had moderate, and 35 (39.8 %) had severe disease. Fourteen patients who had AHI <5 were designated as the habitual snoring group. IMT was detected in 17 (16.7 %) of all patients. In patients with severe OSAS, CCA walls were thicker (p = 0.040) and IMT ratios were higher (p = 0.019) compared to mild/moderate OSAS patients. In patients with IMT, age, AHI, oxygen desaturation index (ODI), and snoring index were higher compared to patients without IMT (p < 0.05). CONCLUSION: Carotid artery IMT, which is an early finding of atherosclerosis, was found to be highly correlated with OSAS and snoring severity.

The role of thoracic ultrasonography in the diagnosis of pulmonary embolism.

OBJECTIVES: The diagnosis of pulmonary embolism (PE) is still a problem especially at emergency units. The purpose of study was to determine the diagnostic accuracy of thoracic ultrasonography (TUS) in patients with PE. METHODS: In this prospective study, 50 patients with suspected PE were evaluated in Department of Pulmonary Diseases of a Training and Reasearch Hospital between January 2010 and July 2011. At the begining, TUS was performed by a chest physician, subsequently for definitive diagnosis computed tomography pulmonary angiography were performed in all cases as a reference method. Other diagnostic procedures were examination of serum d-dimer levels, echocardiography, and venous doppler ultrasonography of the legs. Both chest physician and radiologist were blinded to the results of other diagnostic method. Diagnosis of PE was suggested if at least one typical pleural-based/subpleural wedge-shaped or round hypoechoic lesion with or without pleural effusion was reported by TUS. Presence of pure pleural effusion or normal sonographic findings were accepted as negative TUS for PE. RESULTS: PE was diagnosed in 30 patients. It was shown that TUS was true positive in 27 patients and false positive in eight and true negative in 12 and false negative in three. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of TUS in diagnosis of PE for clinically suspected patients were 90%, 60%, 77.1%, 80%, and 78%, respectively. CONCLUSIONS: TUS with a high sensitivity and diagnostic accuracy, is a noninvasive, widely available, cost-effective method which can be rapidly performed. A negative TUS study cannot rule out PE with certainty, but positive TUS findings with moderate/high suspicion for PE may prove a valuable tool in diagnosis of PE at bedside especially at emergency setting, for critically ill and immobile patients, facilitating immediate treatment decision.

CPAP adherence of patients with obstructive sleep apnea.

BACKGROUND: Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BPAP) are the gold standard treatments for obstructive sleep apnea syndrome (OSAS), but CPAP/BPAP is not well tolerated and requires long-term follow-up. OBJECTIVE: We prospectively assessed subjective and objective adherence and factors that affect adherence in OSAS patients. METHODS: Subjects using CPAP/BPAP were questioned about adverse effects of CPAP/BPAP and were assessed with the Epworth Sleepiness Scale (ESS) at the first, third, sixth, and twelfth month, and once every 6 months after the first year. CPAP/BPAP use and objective and subjective adherence were assessed. Subjects who used CPAP/BPAP for at least 4 hours per night for at least 70% of the days monitored were regarded as adherent, and those who did not were considered non-adherent. The relationships between adherence and demographic data, polysomnography findings, ESS scores, and adverse effects were statistically analyzed. RESULTS: Six-hundred forty-eight subjects who were diagnosed with OSAS by polysomnography and accepted to use CPAP/BPAP in our sleep center between January 2005 and June 2011 were included. Four-hundred fifty-one subjects (69.6%) were men, and 197 (30.4%) were women. Two-hundred forty-eight (38.3%) subjects attended follow-ups, 246 (37.9%) were called by telephone, and 154 (23.8%) could not be reached. Of the whole population, 63.9% had obtained their CPAP/BPAP machine. In the 248 subjects who attended follow-ups, subjective adherence was 85.1% and objective adherence was 64.5%. Improvement in ESS score (P < .001) and satisfactory sleep (P < .001) were found to be significantly higher in the adherent group. Chest discomfort, difficulty falling asleep, and sleep disturbances were significantly higher in the non-adherent group (all P < .01). CONCLUSIONS: Of the whole population, just 38.3% attended follow-ups. The objective adherence was lower than the subjective adherence in subjects who attended follow-ups. Younger subjects were more adherent, and the most important factors that correlated with adherence were substantial improvement of daytime sleepiness and effect of CPAP/BPAP on satisfactory sleep. CONCLUSIONS: CPAP/BPAP adherence should be followed with objective monitoring.

The utility of endobronchial ultrasound-guided transbronchial needle aspiration in mediastinal or hilar lymph node evaluation in extrathoracic malignancy: Benign or malignant?

OBJECTIVE: Newly arising enlarged or hypermetabolic mediastinal/hilar lymph nodes (LNs) in patients with previously diagnosed extrathoracic malignancies raise suspicion of metastasis. Relatively high proportion of these LNs is due to a benign condition. We aimed to determine frequency of malignant LNs and role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for clarification of the origin of suspicious LNs in these patients. METHODS: Consecutive patients with a known extrathoracic malignancy and suspected hilar/mediastinal LN were included in this prospective study. Computed tomography (CT) of thorax and positron emission tomography-CT of all patients were taken. LNs with short axis >1 cm at CT of thorax and SUV ≥ 2.5 were accepted suspicious for malignancy. All patients underwent EBUS-TBNA for pathological verification of LNs. Patients with benign diagnosis either underwent invasive procedures or were followed up. The results were evaluated for frequency of malignant hilar/mediastinal LNs and sensitivity, specificity, and diagnostic values of EBUS-TBNA. RESULTS: A total of 48 cases with a mean age of 57.4±11.6 were included. All cases had the diagnosis of an extrathoracic malignancy. 78 LNs were aspirated with EBUS-TBNA in 48 cases (1.62 LNs/patient). The mean short axis of aspirated LNs was 1.51±0.63. Results of EBUS-TBNA revealed malignancy in 15 cases (31.2%), tuberculosis in six cases (12.5%), sarcoidosis in four cases (8.3%), and reactive adenitis in 23 cases (48%). The sensitivity, specificity, and negative predictive value of EBUS-TBNA for malignancy were 83.3%, 100%, and 90.9%, respectively. When both benign and malignant diseases were considered, sensitivity, specificity, negative predictive value, and diagnostic accuracy of EBUS-TBNA were 89.2%, 100%, 86.9%, and 93.7%, respectively. CONCLUSIONS: The ratio of benign LNs in patients with extrathoracic malignancies is relatively high. EBUS-TBNA is a safe, minimally invasive, and effective method for clarification of intrathoracic LNs.