Does exercise capacity, dyspnea level, or quality of life actually predict mortality in patients with COPD? 8-year follow-up.

INTRODUCTION: The goals of chronic obstructive pulmonary disease (COPD) treatment are to relieve dyspnea, increase exercise capacity, and improve quality of life. The relation of exercise capacity, dyspnea level, and quality of life with long-term mortality is unclear. Aim of the study was to assess the effect of exercise capacity, dyspnea level and quality of life on long-term mortality risk in patients with COPD. MATERIALS AND METHODS: Dyspnea level was assessed using the modified Medical Research Council (mMRC), Borg and Baseline Dyspnea Index (BDI) and Body Obstruction Dyspnea Exercise (BODE), health-related quality of life with St. George's Respiratory Questionnaire, and exercise capacity with the 6-minute walking test (6MWT) and cardiopulmonary exercise test. At the end of 8-year follow-up period, the relation between these tests and mortality was examined. RESULT: A total of 42 patients with stable COPD were included in the study. Sixteen patients died during the approximately 8-year follow-up period. Univariate analysis revealed that VO2 peak [HR: 1.845; CI: (1.336-2.55); p<0.001], BODE index [HR: 0.787; CI: (0.703-0.880); p<0.001], and SGRQ [HR: 1.073; CI: (1.028-1.119); p= 0.001] were significantly correlated to mortality risk. Multivariate Cox regression analysis revealed VO2 peak [HR: 1.031; CI: (0.683-1.120); p= 0.01] as the single significant predictor of mortality. VO2 peak less than 22.5 had a sensitivity of 82%, specificity of 80%, and area under the curve of 0.142 [95% CI: (0.027-0.257); p< 0.001] for mortality risk with ROC analysis. CONCLUSIONS: Cardiopulmonary disturbances during maximal exercise may be an important indicator of mortality risk.

Does the 2017 revision improve the ability of GOLD to predict risk of future moderate and severe exacerbation?

INTRODUCTION: In 2017 update, GOLD separated spirometry from ABCD classification. OBJECTIVES: The aim was to investigate the predictive reliability of GOLD 2017 grading system in terms of future moderate and severe exacerbations. METHODS: COPD patients were classified into A to D groups according to GOLD 2011 and 2017. Patients who were assigned to C/D groups according to GOLD 2011 were divided into subgroups C 1/D1, C2/D2, C3/D3 according to FEV1 % of predicted and exacerbation history. C1/D1 patients defined as FEV1  < 50% predicted and without ≥2 exacerbations or hospitalization in the last year. RESULTS: A total of 225 patients were enrolled. Among them, 25.8% were in groups C1/D1 according to GOLD 2011. These patients shifted to A/B according to GOLD 2017. C1/D1 patients had a significantly higher risk of future moderate and severe exacerbation compared to A/B (P = 0.018). The risk of future moderate and severe exacerbation was significantly higher in patients with a FEV1  < 50% (P = 0.018).The risk of future moderate and severe exacerbation was higher in GOLD 2017 groups A and B compared to GOLD 2011 groups A and B. CONCLUSION: Low FEV1 was an important risk factor for future exacerbations. Downstaging of C1/D1 patients caused heterogeneity in A/B with including patients with low and high risk of future exacerbation. This resulted in a low discriminative power of GOLD 2017 regarding the risk of future exacerbation in groups A and B. This may cause underestimation of disease severity and inadequate treatment especially in A/B patients with low FEV1 .

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.

A comparison of cardiopulmonary exercise test and 6 minute walking test in determination of exercise capacity in chronic obstructive pulmonary disease.

INTRODUCTION: This study aimed to determine the relationship of 6 minute walking test (6MWT) and cardiopulmonary exercise test (CPET) with each other and with the measures of lung functions in patients with chronic obstructive pulmonary disease (COPD). MATERIALS AND METHODS: Pulmonary function tests, 6MWT, and CPET were performed in 36 (35 males, 1 female) patients with moderate and severe COPD. RESULTS: Maximum oxygen uptake was significantly correlated with 6 minute walking distance. Both exercise tests were correlated with pulmonary function tests. However, maximum exercise capacity was more closely correlated with measures of lung function than 6MWT. Both tests were significantly correlated with static lung volumes. Inspiratory capacity (IC) was significantly correlated with 6MWT and CPET parameters. CPET was significantly correlated with diffusion capacity and maximal inspiratory pressure. Airway conductance and resistance tests showed no correlation with the exercise tests. CONCLUSION: 6MWT is a simple and valuable test to determine the exercise capacity of COPD patients. Both 6MWT and CPET are correlated with ventilatory impairment determined by the lung function tests, particularly FEV1, maximum voluntary ventilation (MVV), and IC. However, CPET is an exercise test that more accurately evaluates and provides more detailed information about hyperinflation and respiratory musce strength than 6MWT does.

[Smoking cessation in patients with cardiopulmonary diseases]. / Kardiyopulmoner hastaligi olanlarda sigaranin birakilmasi

OBJECTIVE: To determine the smoking cessation rates of outpatients with cardiopulmonary disease and the differences between non-cardiopulmonary diseases. METHODS: Two hundred and two active smokers with comorbid diseases were prospectively evaluated between September 2004 and January 2008 in this observational study. All of the patients answered Fagerstrom test for nicotine dependence with a regular questionnaire of general characteristics. Behavioral counseling therapies were administered to all of the subjects. Nicotine replacement therapy, bupropion or combination therapies were the pharmacological therapies after running the baseline spirometry and carbon monoxide oximetry tests. Subjects were classified as patients with cardiopulmonary disease (124) and non-cardiopulmonary diseases (78), based on medical history. Student t and Chi-square tests were used for statistical analyses. RESULTS: The age of smoking was similar but total amount of smoked tobacco was higher (p<0.05) in the cardiopulmonary diseases group. In this group, the main smoking cessation reason was the existing disease (51%) (p<0.05). There was no other significant difference between two groups including treatment protocols. The smoking cessation rates were less (40%) with high relapses (12%) in cardiopulmonary diseases group (p<0.01 and p=0.01 respectively). In the subgroup analysis, treatment procedures were equivalent (p>0.05). CONCLUSION: Results of this analysis confirm that, tobacco dependence is still a severe but necessary condition for the patients with cardiopulmonary diseases. Additionally neither of the treatment protocols was superior to the others.

Mycobacterium simiae infection in an immunocompetent patient, with DNA analyses verification.

Mycobacterium simiae is a non-tuberculosis mycobacterium that does commonly cause clinical disease in immunocompromised patients with or without AIDS. We describe a case of M. simiae pulmonary infection in a patient without immunodeficiency syndrome, who had a history of Mycobacterium tuberculosis infections.

[Comparing the effectiveness of different treatment modalities on the smoking cessation rates]. / Farkli tedavi yöntemlerinin sigara birakma basarisi üzerine etkileri.

The social patterns of smoking have changed significantly in the past two decades but smoking is still as prevalent in the lowest socioeconomic groups as it was widespread. For the solution of this enormous problem many kinds of treatment modalities have been proposed but there is no single successful method for quitting. To determine the smoking cessation rates with behavioural treatment, behavioural + pharmacological treatments and compare the differences between each approaches. 371 smokers were prospectively evaluated between 2004 and 2008. At the beginning subjects were classified into two groups: behavioral treatment group (I) and pharmacological + behavioural treatment group (II). Numbers of patients per group were 88 and 283 respectively. According to pharmacological therapy group II was also divided into three subgroups: nicotine replacement treatment (NRT) (regardless of the type and dosage) (IIa), bupropion (IIb) and combination treatment modalities group (IIc). Numbers of patients per subgroups were 185, 70 and 28 respectively. All of the patients were attended the one year follow up visits. According to the baseline characteristics there was no significant difference between the groups and subgroups. At the end of the fist year, in group I smoking cessation rate was 41% and in group II 51% and this was not statistically significant (p< 0.05). In the sub group analysis the success rates for group IIa, IIb and IIc; 44.8%, 62.8% and 64% respectively and bupropion is significantly superior to the NRT (p= 0.01). In study subjects, smoking cessation rates were less with comorbid diseases (p= 0.004), baseline airway obstruction (p= 0.04) and high CO levels (p= 0.008). Results of this analysis confirm that, there is a significant difference between pharmacological treatment and behavioral treatments. Additionally, in the pharmacological approaches, bupropion seems to be superior. Besides, comorbid conditions have been a huge problem to solve.

Acute anuric renal failure with streptokinase therapy in a patient with acute venous thromboembolic disease and the review of renal side effects of streptokinase.

The benefits of thrombolytic therapy in acute myocardial infarction are now well established. However many uncertainties, such as adverse effects, are still remain in venous thromboembolic disease. We describe a unique patient who treated with streptokinase for the methylen tetrahydrofolate reductase mutation associated acute deep vein thrombosis and massive pulmonary embolism. After therapy patient developed acute anuric renal failure without an evidence of bleeding or immunologic reaction and we would like to review the renal side effects of streptokinase in patients with venous thromboembolic disease.

Evaluation of the relationship between radiological abnormalities and both pulmonary function and pulmonary hypertension in coal workers' pneumoconiosis.

OBJECTIVE: The aim of this study was to investigate the effect of the radiological evidence of emphysema, and the extent of interstitial involvement, on lung function and pulmonary arterial pressure (PAP) in patients with coal workers' pneumoconiosis (CWP). METHODS: The records of 48 patients with suspected CWP were evaluated retrospectively. Pulmonary function tests, arterial blood gas analyses and right heart catheterization were evaluated in all patients. Radiological scoring was according to International Labour Organization criteria, and emphysema was scored by CT scanning. Patients were grouped according to the mean PAP (> or =20 mm Hg or < or =19 mm Hg). RESULTS: All patients showed a mild decrease in FEV(1)/FVC and a mild increase in FRC. Forty-four per cent of patients developed mild to moderate pulmonary hypertension. Emphysema scores correlated significantly with airflow rates, including FEV(1)%, FEV(1)/FVC and FEF(25-75%), and with carbon monoxide diffusing capacity (DLCO)% predicted as well as FRC% predicted and the ratio RV/TLC, which are indices of air trapping. Additionally, profusion and global profusion scores showed significant correlation with FEV(1)/FVC, DLCO% predicted, specific airway conductance and smoking. Mean PAP showed a significant negative correlation with FEF(50%) predicted, DLCO% predicted and profusion score. CONCLUSIONS: The impairment of pulmonary function (mainly disturbance in airflow rates and air trapping) and pulmonary hypertension may be present, even in a simple form of CWP. The pulmonary function impairment in patients with CWP is likely to be attributable to the occurrence of emphysema. However, pulmonary hypertension was directly related to the profusion of pneumoconiotic nodules, which may result in obliteration of the vascular bed.

Is there any difference between effects of ipratropium bromide and formoterol on exercise capacity in moderate COPD patients?

The effects of anticholinergic agents or long acting beta(2)-agonists on exercise capacity in chronic obstructive pulmonary disease (COPD) improves various out come measures but there is not enough double-blind study which included comparison of different medications. The aim of this study was to compare the effect of ipratropium bromide and formoterol on exercise capacity and also to determine the relationship between this improvement in functional parameters and exercise capacity for each treatment in patients with COPD. This study was performed as randomized, double blind and two period crossover design. Ten volunteer stable COPD patients were recruited from outpatient COPD clinic. At the initial visit medical data were recorded. One week later baseline measurements; pulmonary function tests and cardiopulmonary exercise testing were performed, afterwards, patients received ipratropium bromide 40 microg four times a day or formoterol 12 microg two times a day for two weeks. After a washout period, medications were crossed for another two weeks. After each of treatment period, all tests were performed. Nine subjects were male and mean age was 51.1 +/- 5.45 years, all of them were heavy smokers, level of COPD was mild to moderate (FEV(1)= 69%, FEV(1)/FVC= 68%). While formoterol significantly improved FEV(1), FEV(1)/FVC %, ipratropium significantly improved FEV(1), FEF(25-75), peak oxygen uptake and minute ventilation. Moreover, both of the medications increased exercise time. There were no differences between effects of ipratropium bromide and formoterol on exercise capacity and functional parameters. We observed that ipratropium bromide and formoterol have similar improvement in exercise capacity in COPD patients. The improvement in exercise capacity also correlated with increase in FEV(1).

Inhaled iloprost as a long-term additional therapy to oral sildenafil in severe idiopathic pulmonary arterial hypertension.

Idiopathic pulmonary arterial hypertension (IPAH) is an uncommon and devastating disease which, if untreated, progresses rapidly and leads to right heart failure and death. The course of the disease has been altered by advances in medical therapies. However, the effects of long-term alternative therapies and responses to each treatment protocols are not definite. We want to define an IPAH case, which had long-term temporary responses to the conventional therapy plus calcium channel blockers treatment and moreover compared the long-term clinical and physiologic effects of oral sildenafil mono therapy and additional inhaled iloprost therapy. Patients with IPAH may have response to a short-term vasodilatation therapy but they have to follow for the long-term results and may be of benefit from combination treatments.