The WHO global alliance against chronic respiratory diseases in Turkey (GARD Turkey).

In order to prevent and control non-communicable diseases (NCDs), the 61st World Health Assembly has endorsed an NCD action plan (WHA resolution 61.14). A package for essential NCDs including chronic respiratory diseases (CRDs) has also been developed. The Global Alliance against Chronic Respiratory Diseases (GARD) is a new but rapidly developing voluntary alliance that is assisting World Health Organization (WHO) in the task of addressing NCDs at country level. The GARD approach was initiated in 2006. GARD Turkey is the first comprehensive programme developed by a government with all stakeholders of the country. This paper provides a summary of indicators of the prevalence and severity of chronic respiratory diseases in Turkey and the formation of GARD Turkey.

Malignant pleural mesothelioma due to environmental mineral fiber exposure in Turkey. Analysis of 135 cases.

We reviewed data from 135 patients with environment-associated malignant pleural mesothelioma (MPM) from the Central Anatolian region of Turkey. The most significant factors suggesting the diagnosis of MPM were the village where the patient resided and the typical presenting symptoms and signs of unilateral exudative pleural effusion associated with nonpleuritic chest pain. Computed tomography and ultrasonography were very useful for evaluating the extension of the tumor in the thoracic and abdominal cavities and chest wall. The tissue diagnosis was established by either thoracoscopy (39 percent) or pleural biopsy (39 percent) in the majority of the cases. The median survival after diagnosis was 13.52 months for erionite-associated MPM and 21.56 months for asbestos-associated MPM. The actuarial survival curves for the fibrous minerals were significantly different for survival computed both from onset of the symptoms and after diagnosis. Medical or surgical treatment or both did not change the outcome of the disease.

Environmental asbestosis complicated by lung cancer.

Diagnosis of asbestosis and bronchiolo-alveolar carcinoma was made in a 55-year-old Turkish woman who was a nonsmoker. She originated from and was living in an area with a high prevalence of environmental diseases attributed to tremolite asbestos. Mineralogic analysis of lung tissue revealed very high concentrations of asbestos bodies (1.64 x 10(6)/g of dry tissue) and tremolite fibers (173.7 x 10(6) of dry tissue). This case illustrates the following points: (1) In some areas, environmental exposure can lead to cumulated fiber retention comparable to occupational exposure and thus can represent a risk for lung fibrosis (asbestosis). (2) Lung cancer as a complication of environmental asbestosis also should be considered as a potential environmental disease.

Echocardiographic evaluation of left and right ventricular diastolic function in patients with chronic obstructive pulmonary disease.

The aim of this study was to investigate the effects of chronic obstructive pulmonary disease (COPD) on left ventricular and right ventricular diastolic and systolic functions. Forty-eight patients with severe COPD were studied. Patients were divided into 2 subgroups according to pulmonary artery pressures: 25 patients with pulmonary hypertension (group 1) and 23 patients with normal pulmonary artery pressure (group 2). As a control group, 59 normal subjects were studied (group 3). Patients in group 1 had higher tricuspid peak A velocity, lower tricuspid E velocity, longer isovolumetric relaxation time, higher mitral A wave, lower mitral E wave, and slower color propagation velocity than groups 2 and 3. There was no significant difference between left ventricular diastolic filling parameters between groups 2 and 3. Patients with COPD and pulmonary hypertension have left and right ventricular diastolic dysfunction. However, patients with COPD and normal pulmonary artery pressure have normal left and right ventricular diastolic function.

An epidemiological study in an Anatolian village in Turkey environmentally exposed to tremolite asbestos.

After several cases of malignant pleural mesothelioma (MPM) were detected in the village of Kureysler in the Kütahya district of western Turkey, an epidemiological study was conducted. A questionnaire was completed by 124 villagers who were older than 20 years and standard posteroanterior chest X-rays were taken. The films were evaluated by three chest physicians. Samples of the white stucco that had been used by almost all villagers for indoor painting for many years were mineralogically examined. Chest X-rays showed that 23 (18%) had pleural plaques and calcifications compatible with asbestos exposure. Male sex and old age were associated with occurrence of pleural plaques. An analysis of white stucco samples revealed tremolite asbestos. In conclusion, tremolite fibers might be the cause of the high incidence of pleural plaques and MPM cases in the village of Kureysler.

Angiocentric T-cell lymphoma of the lung mimicking metastatic carcinoma. Case report.

Angiocentric T-cell lymphoma is a peripheral T-cell lymphoma (PTCL) which typically involves nose and upper respiratory system mostly presenting as a multisystemic disease. Intrathoracic involvement is common in NHL and the most common manifestation is mediastinal lymphadenopathy. However, malignant lymphomas presenting within the lung are rare and may be either primary or a manifestation of widely disseminated disease. We report a case with multiple pulmonary nodules mimicking metastatic carcinoma of the lung. This type of involvement is not common: when extensive, as in our case, differential diagnosis from metastatic carcinoma is essential.

Endobronchial lipoma in a patient with Churg-Strauss syndrome.

Churg-Strauss syndrome (CSS) is a disorder characterized by hypereosinophilia and systemic vasculitis complicating a preexisting asthma. We report here a case of CSS with an endobronchial lesion, initially considered to be an endobronchial granuloma of CSS, which was finally diagnosed as a lipoma, a very rare benign tumor of the tracheobronchial tree. To our knowledge, this is the first case in the literature presenting with these two rare entities.

Effect of the long-term use of inhaled corticosteroids on bone mineral density in asthmatic women.

OBJECTIVE: Inhaled corticosteroids have become a key element in the maintenance treatment of bronchial asthma. Recent studies have shown that administration of inhaled corticosteroids is associated with evidence of derangement in bone turnover. Therefore, we studied the bone mineral density (BMD) of asthmatic women receiving long-term inhaled corticosteroids and compared them with healthy individuals matched for age, sex, menopausal status and body mass index. METHODOLOGY: Thirty-two female patients with bronchial asthma, who had been using inhaled corticosteroids (beclomethasone dipropionate 750-1500 microg/day) regularly for at least 3 months, were included in the study. Bone mineral density measurements were done with dual X-ray absorptiometry in the lumbar area of the spine and the hip. Detailed laboratory examination was also done for the patients and 26 controls. RESULTS: There was a significant decrease in BMD of the patient group at the lumbar region and femur as compared with normal controls. In the patients there was a significant negative correlation between the duration of therapy, daily and cumulative doses, and BMD at the lumbar region but not BMD at the femur. CONCLUSIONS: These results indicate that long-term use of inhaled corticosteroids is associated with significant bone loss in asthmatic women and is especially related to the duration of therapy. Therefore, it is necessary to appropriately screen and give prophylactic treatment to those who are likely to develop osteoporosis from inhaled corticosteroid treatment.

Assessment of environmental asbestos exposure in Turkey by bronchoalveolar lavage.

Environmental or domestic exposure to asbestos fibers originating from local soil is responsible for a high incidence of diseases in large rural areas of Turkey. Bronchoalveolar lavage fluids (BALF) were obtained for 65 Turkish subjects originating from these areas and for 42 Turkish controls. Asbestos bodies (ABs) and uncovered fibers (UFs) were quantified by phase contrast light microscopy. Total fiber burden was determined by transmission electron microscopy. The main asbestos types disclosed were tremolite and to a lesser extent chrysotile. AB and fiber concentrations were higher in environmentally exposed subjects (geometric mean [geometric standard deviation]: 5.20 [6.22] AB/ml, 444 [11.6] tremolite fibers/ml) than in control subjects (0.22 [1.45] AB/ml, 12.0 [15.4] tremolite fibers/ml) (p < 0.001). In subjects environmentally exposed in Turkey, AB burdens on tremolite were in the same range as those on commercial amphiboles in subjects occupationally exposed in Belgium. In Turkish subjects, values above either 1 AB/ml, 3 uncovered fiber/ml in light microscopy, or 300 fibers/ml in electron microscopy indicated usually an abnormal alveolar retention reflecting a significant cumulative exposure from environmental or domestic origin. These observations are probably valid for other areas in the world where diseases associated with environmental exposure to soil- derived asbestos fibers occur and for immigrants originating from these areas.

Malignant pleural mesothelioma caused by environmental exposure to asbestos or erionite in rural Turkey: CT findings in 84 patients.

OBJECTIVE: Malignant pleural mesothelioma in rural Turkey frequently results from environmental exposure to tremolite asbestos or fibrous zeolite (erionite). The aim of this study was to determine the CT features of malignant pleural mesothelioma in patients exposed to asbestos or erionite. MATERIALS AND METHODS: The CT scans of 84 patients with proved malignant pleural mesothelioma were retrospectively evaluated. Twenty patients (24%) had been exposed to erionite and 64 patients (76%) had been exposed to asbestos. The CT scans were interpreted by seven observers who did not know the clinical or pathologic findings. RESULTS: CT scans showed either unilateral pleural thickening or pleural nodules/masses in all patients. Pleural nodules were present in 25 patients (30%) and pleural masses in 44 patients (52%). Pleural effusion was found in 61 patients (73%), mediastinal pleural involvement in 78 (93%), pleural calcifications in 52 (62%), involvement of the interlobar fissures in 64 (76%), and volume contraction in 61 (73%). Reduced size of the hemithorax was significantly correlated with chest wall involvement. On the basis of CT findings, the preassigned staging was changed in 21 patients (25%), including 44% of the patients with disease that had been classified as stage I. CT findings were not significantly different between the patients exposed to erionite and those exposed to asbestos. CONCLUSION: The most common CT findings in cases of malignant pleural mesothelioma were unilateral pleural thickening or pleural nodules/masses with or without effusion. CT provided valuable information on the extent of the disease, which was important for staging. Although the CT features are not pathognomonic, they provide valuable clues to the diagnosis in patients who have been exposed to mineral fibers.

Tuberculous pleural effusions: ultrasonic diagnosis.

Twenty patients with tuberculous pleural effusions were studied with ultrasonography. In 18 patients, ultrasonography demonstrated regular pleural thickening which was less than 1 cm except in 1 case. In 4 cases there were a few pleural nodules, whereas in 2 cases the pleural surface showed small nodularity. The latter finding may be diagnostic for a tuberculous etiology. Eighteen patients had multiple, delicate, mobile septations in the effusions, and a lattice-like appearance had formed in 6 cases. Computed tomography was obtained in 7 cases, and pleural thickening was demonstrated in 6 of them. Ultrasonography is a useful imaging modality in the diagnosis of tuberculous pleurisy.

Life threatening chylous pleural and pericardial effusion in a patient with Behçet's syndrome.

Chylothorax and chylopericardium secondary to thrombosis of the superior vena cava and the innominate and subclavian veins were diagnosed in a patient with Behçet's syndrome. Immunosuppressive treatment, diet, and underwater seal drainage led to a diminished volume of pleural fluid and pericardial fluid and to a diminished concentration of triglyceride in them; pleurodesis with tetracycline was then performed.

Prevalence of asthma and allergic diseases in primary school children in Ankara, Turkey: two cross-sectional studies, five years apart.

The prevalence of allergic diseases is reported to have increased worldwide. Two questionnaire surveys, five years apart, were conducted to evaluate the trend of prevalence rates and possible risk factors among primary school children in Ankara, Turkey. A previous survey in 1992 revealed the lifetime prevalences of asthma, wheezing, allergic rhinitis and atopic dermatitis were 17.4%, 23.3%, 28% and 6.1%, and the prevalences for the last 12 months were 8.3%, 11.9%, 15.4% and 4%, respectively. The survey was repeated with the same questionnaire in the same age group (6-13 years) of the same school in May 1997. The parents of 358 boys and 380 girls completed the questionnaire. The lifetime and last 12 months' prevalences of asthma, wheezing, rhinitis and atopic dermatitis were 16.8%, 22.5%, 18.7%, 6.5%, and 9.8%, 13.3%, 14.1%, 4.3%, respectively. There was a significant change only for the lifetime prevalence of rhinitis (p < 0.001). The rate of indoor smoking had declined from 73.9% to 64%, and pet ownership had risen from 7.9% to 22.9% (p < 0.001 for both). Atopic family history was the most prominent risk factor for all types of allergic disorders. Male gender was a significant risk factor for current asthma and wheezing [odds ratio (OR) = 1.80 and 1.59; 95% confidence intervals (CI) = 1.09-2.98 and 1.01-2.48, respectively], and passive smoking affected the occurrence of allergic rhinitis (OR = 1.84; CI = 1.13-3.00). The prevalence rates of allergic diseases among primary school children in Ankara stabilized during a 5-year period for all diseases other than allergic rhinitis. However, there are changing behavior patterns, i.e. indoor smoking and keeping pet animals, which that may have affected these rates.

Erionite bodies and fibres in bronchoalveolar lavage fluid (BALF) of residents from Tuzköy, Cappadocia, Turkey.

OBJECTIVES: The high incidence of malignant mesothelioma in some villages of Cappadocia (Turkey) is due to environmental exposure to erionite fibres. The aim was to evaluate the fibre burden in bronchoalveolar lavage fluid (BALF) from inhabitants of an erionite village and compare it with Turkish subjects with or without environmental exposure to tremolite asbestos. METHODS: Ferruginous bodies (FBs) and fibres were measured and analyzed by light and transmission electron microscopy (TEM) in the BALF of 16 subjects originating from Tuzköy. RESULTS: FBs were detected in the BALF of 12 subjects, with concentrations above 1 FB/ml in seven of them. Erionite was the central fibre of 95.7% of FBs. Erionite fibres were found in the BALF of all subjects, by TEM, and these fibres were low in Mg, K, and Ca compared with erionite from Tuzköy soil. The mean concentration of erionite fibres in BALF was similar to that of tremolite fibres in Turks with environmental exposure to tremolite. The proportion of fibres longer than 8 microm in BALF represented 35.6% for erionite compared with 14.0% for tremolite. The asbestos fibre concentrations in erionite villagers was not different from that in Turks without environmental exposure to tremolite. CONCLUSION: Analysis of BALF gives information about fibre retention in populations environmentally exposed to erionite for whom data on fibre burden from lung tissue samples are scarce. This may apply to exposed Turks having emigrated to other countries.

Birch pollen related food hypersensitivity: as a para-occupational syndrome.

Two patients presented with allergy to birch pollen and hypersensitivity to hazelnut and apple. Since both of these patients developed pollen sensitivity when they were abroad for occupational purpose, we want to mention this situation as "a para-occupational syndrome".

Prevalence of childhood asthma and allergic diseases in Ankara, Turkey.

The first epidemiologic survey of the prevalence of childhood asthma and other allergic disease in Ankara, Turkey, was done in May 1992. A questionnaire on factors influencing the atopic status and allergic symptoms was distributed to parents of 1226 children aged 6-12 years. In this questionnaire, parents were asked to give information about physician-diagnosed asthma and atopic dermatitis (AD), and self-reported wheezing and rhinoconjunctivitis (perennial or seasonal). The overall response rate was 85% and included 502 boys (48.5%) and 534 girls (51.5%). The lifetime prevalences of asthma, wheezing, rhinoconjunctivitis, and AD were 17.4%, 23.3%, 28%, and 6.1%, respectively, and the reported prevalences for the last 12 months were 8.3%, 11.9%, 15.4%, and 4%, respectively. Asthma and other allergic disease had been recognized in 23.2% of the children during the last year; in half of these, more than one disease was present. Eight percent of the families kept pet animals; 95.4% of children had been breast-fed, of whom 61% for more than 6 months; and at least one person smoked at home in the case of 73.9% of children. Some health insurance was available to 72.8% of the families. Cumulative prevalences of wheezing, rhinoconjunctivitis, and AD were significantly associated with the presence of pets, passive smoking at home, and absence of health insurance. The prevalence of asthma was not affected by any of these factors except atopic family history. In conclusion, asthma and other allergic diseases constitute a major health problem for schoolchildren in Ankara.