Diagnostic yield of conventional transbronchial needle aspiration biopsy (C-TBNA) without an on-site cytopathologist: Experience of 363 procedures in 219 patients.

INTRODUCTION: Conventional transbronchial needle aspiration biopsy (C-TBNA) is a technique in evaluating mediastinal/hilar lymph nodes (LN). We aimed to investigate diagnostic yield (DY) and safety of C-TBNAs performed in a single university clinic. PATIENTS AND METHODS: We retrospectively reviewed 363 consecutive C-TBNA procedures in 219 patients. The DY and its relationship with location, shortest diameter, SUVmax of LN, and number of sampled stations were evaluated. RESULT: Procedures were diagnostic in 257 (71%) LNs. The most common diagnoses were malignancy (n= 109.30%) and granulomatous inflammation (n= 68, 18.7%).The ratio of patients with at least one diagnostic cytology result was 77% (n= 168). DY was significantly increased with the increased number of sampled LNs (p= 0.033) and larger LN diameter (p< 0.001). Sensitivity, specificity, positive, and negative predictive values were 83.3%, 43.2%, 79.6%, and 49.3% respectively for cut-off LN diameter of 11.5 mm. There was nearly a significant relationship between DY and SUVmax (p= 0.05, cut-off= 4.8). The highest DY was in subcarinal LN (77.4%). No major complications were recorded. CONCLUSIONS: The DY of C-TBNA was 71%. The ratio of the patients with at least one diagnostic cytology result was 77%. The most common diagnoses were malignancy and granulomatous inflammation. The DY of C-TBNA was increased with the increased number of sampled LNs, larger LN diameter, and increased SUVmax. C-TBNA is a safe procedure.

Common variable immunodeficiency and pulmonary amyloidosis: a case report.

Common variable immunodeficiency is the most common symptomatic primary immune deficiency characterized by hypogammaglobulinemia, recurrent infections, and increased risk of autoimmune disease and malignancy. Secondary amyloidosis develops from chronic inflammatory conditions. The co-existence of CVID (especially in patients with bronchiectasis) and secondary amyloidosis has been reported rarely. We describe the first case of pulmonary hypertension secondary to pulmonary amyloidosis in a patient with CVID.

The relation between Lp-PLA2 levels with periodic limb movements.

OBJECTIVE: Lipoprotein-associated phospholipase A2 (Lp-PLA2), a novel marker of vulnerable plaque to prone rupture, is a predictor of both cardiovascular event and cerebrovascular event, and highly sensitive-C-reactive protein (hs-CRP) is an acute-phase response protein implicated in a broad range of cardiovascular diseases. We aimed to examine the association between periodic limb movements in sleep (PLMs) with circulating Lp-PLA2 and hs-CRP levels in patients with PLMs. METHODS: Seventy patients with newly diagnosed PLM with polysomnography were enrolled this study. Patients were divided into two groups according to PLM index (normal PLM index, <15; elevated PLM index, ≥15). Lp-PLA2 and hs-CRP concentrations were measured in serum samples by turbidimetric and nephelometric methods, respectively. The concentrations of these parameters were compared between two groups and correlation analysis was performed between PLMs and Lp-PLA2 and hs-CRP levels. RESULTS: Lp-PLA2 levels and hs-CRP were significantly increased in elevated PLM index group compared with the control group (206.8 ± 78.1 vs 157.8 ± 56.7, p = 0.003, and 4.2 ± 3.5 vs 2.4 ± 2.1, p = 0.02, respectively). PLM index was positively correlated with Lp-PLA2 levels (r = 0.40, p = 0.001) and hs-CRP (r = 0.24, p = 0.05). In the linear regression model, Lp-PLA2 was an independent predictor of PLM index (R(2) = 0.36, p = 0.005). CONCLUSION: This study demonstrated an independent linear relation between PLM index and Lp-PLA2. In addition, it was seen increased Lp-PLA2 and hs-CRP levels in patients with elevated PLM index. Based on these results, we can suggest that risk of vascular events may be increased in patients with PLMs and with increased PLM index.

Bronchial anthracofibrosis case with endobronchial tuberculosis.

We reported a case with bronchial anthracofibrosis and endobronchial tuberculosis. Our case demonstrated this possible correlation between anthracofibrosis and endobronchial tuberculosis. We showed this correlation visually and microbiologically.

2009 H1N1 influenza and experience in three critical care units.

AIM: We describe futures of ICU admission, demographic characteristics, treatment and outcome for critically ill patients with laboratory-confirmed and suspected infection with the H1N1 virus admitted to the three different critical care departments in Turkey. METHODS: Retrospective study of critically ill patients with 2009 influenza A(H1N1) at ICU. Demographic data, symptoms, comorbid conditions, and clinical outcomes were collected using a case report form. RESULTS: Critical illness occurred in 61 patients admitted to an ICU with confirmed (n=45) or probable and suspected 2009 influenza A(H1N1). Patients were young (mean, 41.5 years), were female (54%). Fifty-six patients, required mechanical ventilation (14 invasive, 27 noninvasive, 15 both) during the course of ICU. On admission, mean APACHE II score was 18.7±6.3 and median PaO(2)/FIO(2) was 127.9±70.4. 31 patients (50.8%) was die. There were no significant differences in baseline PaO(2)/FIO(2 )and ventilation strategies between survivors and nonsurvivors. Patients who survived were more likely to have NIMV use at the time of admission to the ICU. CONCLUSION: Critical illness from 2009 influenza A(H1N1) in ICU predominantly affects young patients with little major comorbidity and had a high case-fatality rate. NIMV could be used in 2009 influenza A (H1N1) infection-related hypoxemic respiratory failure.

The association among lipoprotein-associated phospholipase A2 levels, total antioxidant capacity and arousal in male patients with OSA.

BACKGROUND: The mechanisms of the increased cardiac and vascular events in patients with OSA are not well understood. Arousal which is an important component of OSA was associated with increased sympathetic activation and electrocardiographic changes which prone to arrhythmias. We planned to examine the association among arousal, circulating Lp-PLA2 and total antioxidant capacity in male patients with OSA. METHODS: Fifty male patients with newly diagnosed OSA were enrolled the study. A full-night polysomnography was performed and arousal index was obtained. Lp-PLA2 concentrations were measured in serum samples with the PLAC Test. Total antioxidant capacity in patients was determined with Antioxidant Assay Kit. RESULTS: Arousal was positively correlated with LP-PLA2 levels (r=0.43, p=0.002) and was negatively correlated with total antioxidant capacity (r= -0.29, p=0.04). Elevated LP-PLA2 levels and decreased total antioxidant activities were found in the highest arousal quartile compared with the lowest and 2nd quartiles (p=0.02, p=0.05, respectively). LP-PLA2 was an independently predictor of arousal index in regression model (ß=0.357, p=0.002) CONCLUSIONS: This study demonstrated a moderate linear relationship between arousal and LP-PLA2 levels. Also, total antioxidant capacities were decreased in the higher arousal index. Based on the study result, the patients with higher arousal index may be prone to vascular events.

Evaluation of performance of quantiferon assay and tuberculin skin test in end stage renal disease patients receiving hemodialysis.

PURPOSE: End stage renal disease (ESRD) cases are associated with increased risk of tuberculosis. There is no gold standard method for detecting latent tuberculosis infection (LTBI) in ESRD. The aim of the present study was to analyze the performance of the tuberculin skin test (TST) and QuantiFERON-TB Gold in tube (QFT-G) in cases receiving hemodialysis (HD). METHODS: The TST and QFT-G were prospectively performed in 96 ESRD cases undergoing HD. The agreement of the QFT-G and TST was assessed in two TST cut off values (10 mm and 5 mm) in Bacille Calmette Guèrin (BCG) vaccinated and non-vaccinated cases. RESULTS: Of 96 cases 67 were BCG vaccinated and 29 were BCG non-vaccinated. QFT-G was positive in 39.6% cases and indeterminate in 3.1%. TST was positive in 43.8% of cases in cut off value of 10 mm and positive in 58.3% of cases in cut off value of 5 mm. Agreement between TST and QFT-G results was fair in both BCG vaccinated and non-vaccinated cases in either cut off values, except in cut off value of 10 mm in BCG vaccinated cases in which the agreement was moderate. CONCLUSION: The agreement between QFT-G and TST test is fair and there is no significant difference in both cut off values of TST in screening of LTBI in ESRD cases receiving HD.

Unexplained acute respiratory distress syndrome after varicocele surgery; report of a case.

Acute respiratory distress syndrome (ARDS) is a syndrome of acute respiratory failure that is associated with several clinical disorders including direct pulmonary injury and indirect pulmonary injury. Vascular surgical patients are at risk for ARDS. A 23-year old man was admitted to our respiratory intensive care unit with short of breath, cyanosis and agitation which was developed acutely after varicocele operation under epidural anesthesia lasted for one hour. Bupivacain, fentanyl, remifentadyl and midazolam were used for epidural anesthesia. Oxygen saturation was 81% while breathing oxygen at FiO(2) of 0.5. Arterial blood gas analysis showed hypoxemia with respiratory alkalosis with a PaO(2)/FiO(2) score of 100. A chest radiograph demonstrated bilateral alveolar opacities. Bedside echocardiography was performed which revealed no evidence of global hypokinesia, all the chambers were normal, left ventricular ejection fraction was 65%. A diagnosis of ARDS was made and the patient was initiated on noninvasive mechanical ventilation. He was gradually weaned off the NIMV and discharged after a total hospital stay of four days. We report an ARDS case due to unexplained etiology after varicocele operation under epidural anesthesia and managed successfully with noninvasive mechanical ventilation.

Ankylosing spondylitis with mycetoma case treated with oral itraconazole.

Pleuropulmonary involvement is an uncommon event in the course of ankylosing spondylitis (AS). Apical fibrosis, interstitial infiltrates, and pleural thickening were considered to be the main patterns. However, the presence of cavity is very rare in AS. Here, we report an AS case with aspergilloma, which has been successfully treated with itraconazole.

Acute sleep deprivation is associated with increased QT dispersion in healthy young adults.

BACKGROUND: Sleep deprivation (SD) is known to be associated with worse cardiovascular outcome including mortality. We investigated the association between acute SD and electrocardiographic maximum QT interval (QTmax), QT, and corrected QT dispersion (QTd/cQTd), which are known to be among predictors of ventricular arrhythmias and sudden death. METHODS: We obtained electrocardiograms of 37 healthy young volunteers (age: 28.45 +/- 7.97 years; 11 women) after a night with regular sleep and repeated after a night with sleep debt. We measured minimum QT interval (QTmin), QTmax, QTd, and cQTd in milliseconds. RESULTS: Average sleep time of the subjects were 7.7 +/- 0.8 hours during regular sleep and 1.7 +/- 1.6 hours during a night with sleep debt (P < 0.001). Subjects had similar values of QTmin in milliseconds after a night of sleep debt when compared to after regular sleep (347.56 +/- 29.75 vs 344.59 +/- 20.89; P = 0.51), whereas they had significantly higher values of QTmax, QTd, and cQTd (396.48 +/- 30.11 vs 378.10 +/- 23.90; P = 0.001, 49.45 +/- 9.11 vs 33.51 +/- 10.05; P < 0.001 and 54.92 +/- 10.42 vs 37.23 +/- 10.81; P < 0.001, respectively). In Pearson's correlation analysis, QTmax, QTd, and cQTd were inversely correlated with sleep time (P = 0.012, r =-0.291; P < 0.001, r =-0.625 and P < 0.001, r =-0.616, respectively) CONCLUSIONS: In conclusion, we clearly demonstrated that even one night of SD is associated with significant increase in QTmax, QTd, and cQTd in healthy young adults despite remaining within normal limits. These electrocardiographic changes in acute SD might contribute to development and/or recurrence of arrhythmias. This implication deserves further studies for clarifying the possible linkage between SD and arrhythmias.

Triple test with tumor markers CYFRA 21.1, HE4, and ProGRP might contribute to diagnosis and subtyping of lung cancer.

BACKGROUND AND AIM: Early diagnosis and histological subtyping are important issues in the management of patients with lung cancer (LC). The aim of this study is to investigate the diagnostic value of a panel of serum tumor markers in newly diagnosed patients with LC. METHODS: Venous blood samples were collected from 99 patients with LC (42 adenocarcinoma, 35 squamous, and 22 small cell carcinoma) and 30 patients with benign lung disease. Progastrin releasing peptide (ProGRP), squamous cell carcinoma antigen (SCCAg), cytokeratin 19-fragments (CYFRA 21.1), human epididymis protein 4 (HE4), Chromogranin A (CgA) and neuron specific enolase (NSE) levels were measured. The diagnostic value of the biomarkers was assessed with ROC curve analyses; the area under the curve (AUC) was calculated. RESULTS: Serum CYFRA 21.1, ProGRP, SCCAg, NSE levels were significantly higher in LC patients. While ProGRP levels were higher (p = 0.009) in SCLC; CYFRA 21.1 and SCCAg levels were higher in NSCLC (p = 0.019 and p = 0.001, respectively). The sensitivity and specificity of tumor markers were 72%, 83% for CYFRA 21.1; 70%, 57% for HE4; 18%, 93% for ProGRP; 43%, 77% for SCCAg; 54%, 53% for CgA; 73%, 50% for NSE. CYFRA 21.1 (p < 0.001, r = 0.394), HE4 (p = 0.014, r = 0.279) and CgA (p = 0.023, r = 0.259) levels were positively correlated with tumor stage in NSCLC. CgA levels were significantly higher in extensive stage SCLC (p = 0.004). CYFRA 21.1 had the highest diagnostic value for LC (AUC = 0.865). When it is combined with HE4, diagnostic value increased (AUC = 0.899). ProGRP had the highest diagnostic value (AUC = 0.875, p < 0.001) for discriminating SCLC from NSCLC. CONCLUSION: A panel of three tumor markers CYFRA 21.1, HE4 and ProGRP may play a role for discriminating LC from benign lung disease and subtyping as SCLC.

[A multiple myeloma case presenting with bilateral pleural involvement]. / Bilateral plevral tutulum ile basvuran multipl miyelom olgusu.

Pleural effusion is a relatively infrequent finding in multiple myeloma (MM) and malign effusions due to myelomatous effusion is seen very rarely. In this article we reported a case with bilateral myelomatous effusion. Myelomatous etiology was detected by demonstrating gammopathy in pleural fluid protein electrophoresis and demonstrating abundant number of atypical plasma cells in pleural fluid cytology. Pleural fluids due to MM are usually seen in IgA type of MM's, IgG on the surface of CD-138 positive cell was demonstrated in flow cytometric study of the pleural fluid of the reported case. In conclusion we mentioned that a patient who does not have diagnosis of MM before may present with pleural involvement, the involvement may be bilateral and flow cytometry can be used in diagnosis.

Diagnostic yield of closed pleural brushing.

The aim of this study was to assess the diagnostic yield of closed pleural brushing (CPBR) in the diagnosis of malignant pleural effusion. Twenty-one adult patients (20 men and 1 woman); aged 62.9 +/- 8.6 were participated to this prospective study. Thoracentesis, CPBR and closed pleural biopsy (CPB) following the brushing were applied to every patient. While CPBR provided diagnosis in 12 (57.1%) of 21 cases, in 3 of these 12 cases, pleural fluid cytology (PFC) and CPB were negative. The sensitivities of PFC, CPBR and CPB in the diagnosis of malignant effusions were 33%, 57% and 52%, respectively. When three procedures were used in combination, the sensitivity increased to 67%. When CPBR is performed in addition to PFC and CPB, the yield of the diagnosis increased 14% additionally. There was no mortality due to these interventions. Complications were chest pain in 3 (14.2%) cases, hypotension in 2 (9.5%) cases, cough in 1 (4.8%) case, pneumothorax in 1 (4.8%) case, and hemothorax in 1 (4.8%) case. In conclusion, CPBR as a safe, simple and well tolerated procedure provides high diagnostic yield in diagnosis of patients with malignant pleural effusion.

Cigarette smoke and bleomycin-induced pulmonary oxidative stress in rats.

Bleomycin causes pulmonary fibrosis by increasing free oxygen radicals. Cigarette smoke is a strong oxidant which adversely affects pulmonary tissue. We evaluated the effects of cigarette smoke administered with intratracheal bleomycin on pulmonary tissue. We studied 3 groups of rats (n=10): one group received intratracheal saline and served as a control; one received intratracheal bleomycin (IT) (0.5 U/100 g body weight, single dose on the first day), and one group received intratracheal bleomycin (single dose on first day) and tobacco smoke (two times per day) (IT-S). After 4 weeks, the levels of malondialdehyde (MDA) and nitric oxide (NO) and the activities of superoxide dismutase (SOD) and xanthine oxidase (XO) were assayed in the homogenate of the lung tissue samples. The severity of interstitial fibrosis was assessed using the grading system described by Ashcroft. There was more intensive fibrosis in the IT and IT-S than in the control samples (P<0.001). The levels of MDA, NO and activity of XO were significantly increased (P<0.001, <0.002 and <0.002, respectively), and SOD activity (P<0.001) was significantly decreased in the IT group when compared to these values in the control group. The concentration of NO was significantly decreased (P<0.002), and SOD activity was significantly increased (P<0.05) in the lung tissue samples of the IT-S group. Theoretically, the combination of cigarette smoke and bleomycin may have a synergistic effect on oxidative lung injury. In conclusion, we showed that inhalation of cigarette smoke provides protection against oxidative stress in the lung tissue of rats with bleomycin-induced pulmonary fibrosis.

The acute effect of bi-level positive airway pressure on heart rate variability in chronic obstructive pulmonary disease patients with hypercapnic respiratory failure.

OBJECTIVE: Non-invasive mechanical ventilation (NIMV) has the potential to improve sympathovagal control of heart rate. The aim of this study was to investigate the acute effects of NIMV on heart rate variability (HRV) in chronic obstructive pulmonary disease (COPD) patients with hypercapnic respiratory failure (HRF). METHODS: In this prospective study 28 COPD patients (64+/-10 years) with HRF underwent electrocardiographic Holter monitorization. Both time domain (TD) and frequency domain (FD) means of HRV analysis were measured for two hours before and during NIMV application. For the TD, mean-RR, SDNN, SDANN, SDNN index, RMSSD, pNN50 and HRV triangular index were measured. For FD, high frequency (HF) and low frequency (LF) were detected. To compare HRV parameters before and during bi-level positive airway pressure (BiPAP) application; paired sample t test was used for normally distributed variables and Wilcoxon signed rank test was used for the variables that were not normally distributed. Pearson correlation test was used to analyze the correlation between HRV and blood gas parameters during BiPAP application. RESULTS: High frequency power of HRV (39 (18-65) ms2 vs. 28 (12-50) ms2, p<0.05), HRV triangular index (9 (3-17) units vs. 6 (2-13) units, p<0.05) and pNN50 (59% (13-110) vs. 42% (5-84), p<0.05), were higher during NIMV than before noninvasive mechanical ventilation. CONCLUSIONS: We think that NIMV may improve heart rate variability indices of parasympathetic modulation of heart rate in COPD cases with HRF and decrease arrhythmic potential.

Relationship between arterial blood gas values, pulmonary function tests and treadmill exercise testing parameters in patients with COPD.

OBJECTIVE: There have been controversial reports regarding the relationship between exercise tolerance and resting pulmonary function in patients with COPD. The aim of this study was to examine the relationship between resting pulmonary function tests (rPFT) and cardiopulmonary exercise testing parameters (CETP) and their value in estimating exercise tolerance of patients. METHODOLOGY: In total, 45 patients with COPD (nine females, 36 males; mean age 61.2 +/- 11.2) and 21 healthy subjects (four females, 17 males; mean age 60.3 +/- 9.7) as a control group were studied. COPD patients (group I) were divided into three subgroups according to their FEV(1) (mild/group II: FEV(1) 60-79% of predicted; moderate/group III: FEV(1) 40-59%; severe/group IV: FEV(1) < 40%). In controls FEV(1) was >/= 80%. RESULTS: There were significant correlations between FEV(1) and CETP in group III (maximal O(2) consumption (mVO(2)), r= 0.35, P < 0.005; total treadmill time (TTT), r= 0.31, P < 0.01; total metabolic equivalent values (TMET), r= 0.29, P < 0.01)) and in group IV (mVO(2), r= 0.49, P < 0.001; TTT, r= 0.45, P < 0.005; TMET, r= 0.31, P < 0.01; peak heart rate (pHR), r= 0.29, P < 0.02; frequency of ventricular extrasystole (fVES), r=-0.27, P < 0.05). Additionally, in group IV there were significant correlations between PaO(2) and CETP (mVO(2), r= 0.41, P < 0.02; TTT, r= 0.38, P < 0.03; TMET, r= 0.31, P < 0.05; pHR, r= 0.29, P < 0.05; fVES, r=-0.28, P < 0.05). CONCLUSION: There are significant correlations of resting FEV(1)% predicted and PaO(2) values with CETP in patients with moderate and severe COPD and these parameters may also have a role as indicators of exercise tolerance in these COPD patients.