Economic burden of lung cancer in Turkey: a cost of illness study from payer perspective.

BACKGROUND: This study was designed to estimate economic burden of lung cancer in Turkey from payer perspective based on expert panel opinion on practice patterns in clinical practice. METHODS: In this cost of illness study, direct medical cost was calculated based on cost items related to outpatient visits, laboratory and radiological tests, hospitalizations/interventions, drug treatment, adverse events and metastasis. Indirect cost was calculated based on lost productivity due to early retirement, morbidity and premature death resulting from the illness, the value of lost productivity due to time spent by family caregivers and cost of formal caregivers. RESULTS: Cost analysis revealed the total per patient annual direct medical cost for small cell lung cancer to be €8772), for non-small-cell lung cancer to be €10,167. Total annual direct medical cost was €497.9 million, total annual indirect medical cost was €1.1 billion and total economic burden of lung cancer was €1.6 billion. Hospitalization/interventions (41%) and indirect costs (68.6%) were the major cost drivers for total direct costs and the overall economic burden of lung cancer, respectively. CONCLUSIONS: Our findings indicate per patient direct medical costs of small cell lung cancer and non-small-cell lung cancer to be substantial and comparable, indicating the substantial economic burden of lung cancer in terms of both direct and indirect costs. Our findings indicate that hospitalization/interventions cost item and indirect costs were the major cost drivers for total direct costs and the overall economic burden of lung cancer, respectively. Our findings emphasize the potential role of improved cancer prevention and early diagnosis strategies, by enabling cost savings related to drug treatment and metastasis management cost items, in sustainability of cancer treatments.

Transbronchial cryobiopsy for diagnosing parenchymal lung diseases: real-life experience from a tertiary referral center.

BACKGROUND AND OBJECTIVES: Transbronchial cryobiopsy (cryo-TBB) is increasingly being used in the diagnosis of diffuse parenchymal lung diseases (DPLD). Varying diagnostic success and complication rates have been reported. Herein we report our experience with cryo-TBB, focusing on diagnostic yield, factors affecting diagnosis, and safety. METHODS: This retrospective study was conducted in a tertiary referral chest diseases hospital. Data regarding the patients, procedures, complication rates, diagnostic yield, and the final diagnosis made by a multidisciplinary committee at all diagnosis stages were evaluated. RESULTS: We recruited 147 patients with suspected DPLD. The definitive diagnosis was made pathologically in 98 of 147 patients (66.6%) and using a multidisciplinary approach in 109 of 147 (74.1%) cases. The number of samples had a significant effect on diagnostic success. Histopathologic diagnostic yield and diagnostic yield with a multidisciplinary committee after a single biopsy were 50%, and histopathological diagnostic yield and diagnostic yield with multidisciplinary committee increased to 71.4% and 85.7%, respectively, with a second biopsy (p = 0.034). The incidence of mild-to-moderate hemorrhage was 31.9%; no severe hemorrhage occurred. Pneumothorax rate was 15.6%, and the mortality rate was 0.68%. CONCLUSIONS: Cryo-TBB has sufficient diagnostic yield in the context of a multidisciplinary diagnosis with acceptable complication rates. Performing at least 2 biopsies and from at least 2 segments increases diagnostic success.

Results of Tobramycin Inhalation Therapy in Patients with Noncystic Fibrosis Bronchiectasis with Pseudomonas aeruginosa Colonization: Real Life Management.

Background: Inhaled antibiotics for treating bronchiectasis have been investigated in the cystic fibrosis population since 1981 and long-term clinical benefits have been reported. However, studies on noncystic fibrosis bronchiectasis (NCFB) have only been performed more recently. Owing to limited evidence, inhaled antibiotics are not currently approved for treating NCFB by the U.S. Food and Drug Administration and the European Medicines Agency. The aim of this study was to evaluate the efficacy and safety of tobramycin inhalation therapy in patients with bronchiectasis with Pseudomonas aeruginosa (PA) colonization. Methods: In this retrospective cross-sectional study, NCFB patients who were Pseudomonas positive on three consecutive cultures 1 month apart and receiving tobramycin inhalation therapy were evaluated. Evaluation of the following parameters was done in this study: age, gender, smoking history, symptoms, pulmonary function test results, sputum culture results, tobramycin treatment duration, side effects of tobramycin and response evaluation, and hospital admissions before and after treatment. Treatment with 300 mg tobramycin through nebulizer twice daily for 28 days on-off cycles for a total of 6 months was considered to be one treatment period. The approvals for the study were received by the local ethics committee and institutional review board. Results: Of the 27 patients, 21 patients completed the first period, 7 patients completed the second period, 4 patients completed the third period, and 1 patient completed the fourth period. Sputum culture was negative in 10 (47.6%) of the 21 patients who completed the first period. Decreased sputum purulence and quantity, dyspnea, and cough were observed during treatment. The frequency of hospitalizations before treatment was 1.24 ± 1.36, whereas after treatment, it decreased to 0.52 ± 0.91, this difference was statistically significant (p = 0.019). The most common side effect was increased dyspnea after nebulization in five patients. Conclusion: Tobramycin inhalation appears to be a well-tolerated treatment in patients with PA colonization with bronchiectasis. This treatment may decrease the hospitalization rates and improve the symptoms.

Real life results of coil treatment for bronchoscopic lung volume reduction in emphysema.

INTRODUCTION: The lung volume reduction coil treatment is a minimally invasive bronchoscopic treatment option for emphysema patients who suffer from severe hyperinflation. Previous studies have reported successful outcomes in selected cases using coil for bronchoscopic lung volume reduction (BLVR). Our aim is to determine the changes in respiratory function tests, perception of dyspnea and exercise capacities after 12 months in patients treated with endobronchial coil. MATERIALS AND METHODS: The data of patients with severe emphysema and treated with coils between 2014-2017 were evaluated retrospectively. Dynamic and static lung volume capacities at baseline and 12 months, modified Medical Research Council (mMRC) questionnaire and six-minute walk test (6-MWT) results were recorded. RESULT: BLVR was performed in thirty patients (one female, twenty-nine males). Five patients were treated bilaterally and twentyfive unilaterally. One patient died after 7 days and 4 patients died during follow-up. Five patients were lost to follow-up. A total of twenty patients with available data were included in the study. A statistically significant difference was found in mMRC results in pre-treatment and 12-month evaluations. There was no significant difference in FEV1, TLC and RV values at the end of 12 months. There was an increase of 18.9 meters (± 83.5 m) between the baseline and 12 months in 6-MWT. 45% of the patients improved their walking distance over 26 meters which is known as minimal clinically important difference (MCID). CONCLUSIONS: Although no significant changes were observed in pulmonary function tests and lung volumes, the increase in exercise capacity and decreased perception of dyspnea indicate the efficacy of endobronchial coil.

The impact of co-existing comorbid diseases on long-term mortality in bronchoscopic lung volume reduction.

Aim Emphysema is a lung disease in which alveolar capillary units are destroyed supporting tissue lost. Bronchoscopic lung volume reduction (BLVR) is a novel treatment for emphysema. Several comorbidities have been reported to coexist in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to evaluate comorbidities of patients with severe emphysema who underwent BLVR and association of these comorbidities with mortality. Methods Between January 2011 and December 2017 the records of severe emphysema patients who underwent endobronchial valve (EBV) or lung volume reduction coil (LVRC) placement were reviewed retrospectively. Results There were 37 patients who received EBV therapy and 29 received LVRC therapy. There were no significant differences in the demographic and clinical characteristics between two groups before the treatment. There were seven deaths (10.6%) over the period of twelve months following the BLVR treatment. All deaths occurred in patients with at least one comorbid condition. Mortality was increased in the presence of comorbidities (14.3% vs 0%, respectively; p=0.099), and it was significantly increased in the presence of multiple comorbidities (18.5% vs 0%; p=0.059). The mortality rate was higher (37.5% vs 10.5%) in the LVRC comparing to the EBV treatment group in the presence of multiple comorbid conditions, albeit not reaching statistical significance (p=0.099). Conclusion The presence of more than one comorbidity in patients who underwent the LVRC treatment are associated with significant increase of mortality. For patients with severe emphysema who have more than one comorbidity, EBV is a better choice than LVRC.

Is there any effect of smoking status on severity and mortality of hospitalized patients with COVID-19 pneumonia?

INTRODUCTION: The Severe Acute Respiratory Syndrome (SARS-CoV-2) virus, which emerged from China and spread all over the world, has affected the world in every aspect and will do so in the foreseeable future. This study was carried out to investigate the possible aggravating effect of smoking on the prognosis of patients with COVID-19 pneumonia presenting with pulmonary involvement. MATERIALS AND METHODS: 114 adult patients who received inpatient treatment in our clinic with the diagnosis of COVID-19 pneumonia between 11 March 2020 and 30 April 2020 were retrospectively included in the study; in particular, they were evaluated in terms of smoking history, severity of disease, need for NIMV and ICU admission, and mortality during their hospitalization. RESULT: The mean age of the 114 patients hospitalized with COVID-19 pneumonia was 51.14 ± 14.97 (range 16-81), and 77 (67.5%) were male. Of the patients, 19 (15.9%) were active smokers, 23 were ex-smokers (20.1%), 72 (63.1%) non-smokers. The effect of smoking on the severity of the disease, length of hospitalization, need for non-invasive mechanical ventilation (NIMV) and intensive care unit (ICU) admission and mortality were not statistically significant. CONCLUSIONS: The rate of active smoking in patients hospitalized with COVID- 19 is lower than the population average. In this study, no correlation was observed between smoking status and the severity, prognosis and mortality of the disease. Further studies with larger number of patients and case series are needed to better elucidate the relationship between smoking and COVID-19 and the pathophysiologic mechanisms of the effects of smoking on the natural history of COVID-19 pneumonia.

A novel biomarker in the diagnosis of parapneumonic effusion: neutrophil gelatinase-associated lipocalin.

BACKGROUND: The protein neutrophil gelatinase-associated lipocalin (NGAL) is a mediator synthesized and released by neutrophils. Its physiological function is as yet unclear. Levels in blood increase in several inflammatory diseases. High serum values indicate poor prognosis for several diseases. Pleural effusion may appear as the result of various pathologies. The most common cause is heart failure (HF). Other common causes include parapneumonic (PPE) and malignant (MPE) pleural effusions, and pulmonary embolism. Tubercular effusion (TE) is commonly encountered in Turkey and similar developing countries. The purpose of this study was to investigate the effectiveness of NGAL, a current inflammation marker, in discriminating between different etiological diseases that cause pleural effusion. METHODS: The study was performed at the Recep Tayyip Erdogan University Faculty of Medicine Chest Diseases Clinic. One hundred patients were included in the study, 25 with parapneumonic effusion, 25 with heart failure-related effusion, 25 with tubercular effusion and 25 with cancer-related effusion. NGAL was measured in patients' serum and pleural fluids. RESULTS: Serum NGAL levels in PPE (171 ± 56 ng/ml) were significantly higher (p < 0.001) than those in HF (86 ± 31 ng/ml), CA (103 ± 42 ng/ml) and TE (63 ± 19 ng/ml). Pleural NGAL levels were also significantly higher in PPE compared to HF, MPE and TE (p < 0.001). Serum NGAL levels exhibited a positive correlation with white blood cell (WBC), neutrophil, C-reactive protein (CRP), sedimentation, serum LDH, creatinine, pleural leukocyte and pleural neutrophil numbers. The most significant correlation was between NGAL level and WBC (p < 0.001, r = 0.579). Both serum and pleural NGAL levels are highly effective in differentiating patients with PPE from those without PPE (AUC: 0.910 and 0.790, respectively). CONCLUSIONS: NGAL can be used in the diagnosis of diseases with an acute inflammatory course. Serum and pleural NGAL levels can differentiate PPE from other diseases causing pleural fluid with high sensitivity and specificity.

[Elevated pleural copeptin levels can distinguish to exudate from transudates]. / Yüksek plevral copeptin düzeyleri eksüdayi transüdadan ayirabilir.

INTRODUCTION: Copeptin is released simultaneously along with arginine-vasopressine as a result of different stimuli from the neurohypophysis. Physiological function of copeptin is still unclear. Increased blood copeptin levels is associated with poor prognosis in many diseases. Pleural effusion is a common clinical condition. The most common causes of pleural effusions are heart failure, parapneumonic effusion, pulmonary embolism and malignacy.Tuberculosis is one of the other major causes of pleural effusion in developing countries. In this study, we aimed to assess whether pleural copeptin level may be a new discriminative biomarker for exudates and transudates pleural effusions. MATERIALS AND METHODS: Research was done at Recep Tayyip Erdogan University School of Medicine in the Department of Chest Diseases. The concentrations of pleural copeptin and typical pleural and serum marker levels were measured in 76 subjects with pleural effusions including 22 transudates caused by congestive heart failure (CHF), and 54 exudates including 18 parapneumonic (PPE), 18 tuberculous pleural effusions (TBPEs), 18 malignant effusions (MPEs). RESULTS: Median pleural fluid copeptin levels were higher in exudates than in transudates (1936 ng/mL and 1313 pg/mL, p value < 0.001). There was no statistical significancy for pleural fluid copeptin levels with in-group exudates (n= 54). Pleural copeptin levels of exudates, with a cut off value of 1469 ng/mL, yielded a 79.6% sensitivity, 81.8% specificity, with an are a under the curve of 0.851. CONCLUSION: Pleural copeptin level is a new biomarker to separate exudates from transudates. Pleural effusion discriminative effect of copeptin is lower than plasma protein level and plasma lactat dehydrogenase (LDH). Pleural copeptin measurement is not recommended for routine clinical use. Pleural copeptin level is not contribute to different iate exudative pleural fluids from each other like PPE, TBPE and MPE.

Prevalence of occupational asthma and respiratory symptoms in foundry workers.

This cross-sectional study was conducted in a foundry factory to assess the prevalence of respiratory symptoms and occupational asthma in foundry workers. Physical examination, spirometric evaluation, chest radiograph, and a questionnaire related to respiratory symptoms were performed. Monitoring of peak expiratory flow rates, spirometric reversibility test, and high-resolution computed tomographies were performed for the participants having respiratory symptoms and/or impaired respiratory function test. A total of 347 participants including 286 workers from production department and 61 subjects who worked in nonproduction departments were enrolled in this study. It is found that phlegm (n: 71, 20.46%) and cough (n: 52, 14.98%) were the most frequent symptoms. The other symptoms were breathlessness (n: 28, 8.06%), chest tightness (n: 14, 4.03%), and wheezing (n: 7, 2.01%) . The prevalence of occupational asthma was found to be more frequent among the subjects who worked in the production department (n: 48, 16.78% ) than the other persons who worked in the nonproduction department (n: 3, 4.91%) by chi-square test (P: 0.001). To prevent hazardous respiratory effects of the foundry production, an early diagnosis of occupational asthma is very important. Cessation of cigarette smoking and using of protective masks during the working time should be encouraged.

The clinical utility of pleural YKL-40 levels in diagnosing pleural effusions.

BACKGROUND AND OBJECTIVE: Recent evidence suggests that YKL-40 is a relatively new biomarker of inflammation and it is involved in the pathogenesis of several pulmonary diseases. Details of serum and pleural YKL-40 in pleural effusions however, remain unknown. We aimed to assess whether serum and pleural YKL-40 is an accurate biomarker of pleural effusions. METHODS: This clinical study was prospective, observational and cross-sectional. The concentrations of serum and pleural fluid YKL-40 and conventional pleural marker levels were measured in 80 subjects with pleural effusions, including 23 transudates caused by congestive heart failure (CHF), and 57 exudates including 23 parapneumonic, 22 malignant and 12 tuberculous pleural effusions (TBPEs). RESULTS: Median pleural fluid YKL-40 levels were higher in exudates than in transudates (219.4 and 205.9 ng/mL, respectively, P<0.001). High pleural YKL-40 levels, with a cutoff value of >215 ng/mL, yielded a 73% sensitivity, 73% specificity, likelihood ratio 2.8 for diagnosing exudate, with an area under the curve of 0.770 [95% confidence intervals (CI): 0.657-0.884]. Pleural YKL-40/serum YKL-40 ratio >1.5 yielded a 75% sensitivity, 72% specificity and likelihood ratio 2.6 for diagnosing TBPE, with an area under the curve of 0.825 (95% CI: 0.710-0.940). CONCLUSIONS: High concentrations of pleural YKL-40 level may help to differentiate exudate from transudate and a high pleural YKL-40/serum YKL-40 ratio may be helpful in seperating TBPE from non-tuberculous effusions.

Right sided arcus aorta as a cause of dyspnea and chronic cough.

BACKGROUND: Right sided arcus aorta (RSAA) is a rare condition that is usually asymptomatic. Patients may present with exertional dyspnea and chronic cough. A recent article suggested that RSAA should be included in the differential diagnosis of asthma, especially in patients with intractable exertional dyspnea. We aimed to present the clinical, radiologic and spirometric features of thirteen patients with RSAA observed in four years at the Rize Education and Research Hospital and Samsun Chest Diseases and Thoracic Surgery Hospital. METHODS: The characteristics of patients with RSAA, including age, gender, symptoms, radiologic and spirometric findings, were retrospectively evaluated. RESULTS: A total of thirteen patients were diagnosed with RSAA. Their ages ranged from 17 to 86 years and the male to female ratio was 11:2. Seven of the patients (54%) were symptomatic. The most common symptoms were exertional dyspnea, dysphagia and chronic cough. Five patients had received treatment for asthma with bronchodilators. Spirometry showed intrathoracic tracheal obstruction in five patients. CONCLUSIONS: The RSAA anomaly occurs more frequently than might be estimated from the number of patients who are detected. Patients with intractable exertional dyspnea and chronic cough should be evaluated for the RSAA anomaly by thoracic CT.