Issue 3-The occupational burden of respiratory diseases, an update.

INTRODUCTION AND AIMS: Workplace exposures are widely known to cause specific occupational diseases such as silicosis and asbestosis, but they also can contribute substantially to causation of common respiratory diseases. In 2019, the American Thoracic Society (ATS) and the European Respiratory Society (ERS) published a joint statement on the occupational burden of respiratory diseases. Our aim on this narrative review is to summarise the most recent evidence published after the ATS/ERS statement as well as to provide information on traditional occupational lung diseases that can be useful for clinicians and researchers. RESULTS: Newer publications confirm the findings of the ATS/ERS statement on the role of workplace exposure in contributing to the aetiology of the respiratory diseases considered in this review (asthma, COPD, chronic bronchitis, idiopathic pulmonary fibrosis, hypersensitivity pneumonitis, infectious pneumonia). Except for COPD, chronic bronchitis and infectious pneumonia, the number of publications in the last 5 years for the other diseases is limited. For traditional occupational lung diseases such as silicosis and asbestosis, there are old as well as novel sources of exposure and their burden continues to be relevant, especially in developing countries. CONCLUSIONS: Occupational exposure remains an important risk factor for airways and interstitial lung diseases, causing occupational lung diseases and contributing substantially in the aetiology of common respiratory diseases. This information is critical for public health professionals formulating effective preventive strategies but also for clinicians in patient care. Effective action requires shared knowledge among clinicians, researchers, public health professionals, and policy makers.

Neurophysiologic cut off values for safe resection of patients with supratentorial gliomas.

BACKGROUND: Gliomas have infiltrative nature and tumor volume has direct prognostic value. Optimal resection limits delineated by high-frequency monopolar stimulation with multipulse short train technique is still a matter of debate for safe surgery without (or with acceptable) neurological deficits. It is also an enigma whether the same cut-off values are valid for high and low grades. We aimed to analyze the value of motor mapping/monitoring findings on postoperative motor outcome in diffuse glioma surgery. METHODS: Patients who were operated on due to glioma with intraoperative neuromonitorization at our institution between 2017 and 2021 were analyzed. Demographic information, pre- and post-operative neurological deficit, magnetic resonance images, resection rates, and motor evoked potential (MEP) findings were analyzed. RESULTS: Eighty-seven patients of whom 55 had high-grade tumors were included in the study. Total/near-total resection was achieved in 85%. Subcortical motor threshold (ScMTh) from resection cavity to the corticospinal tract was ≤ 2mA in 17; 3 mA in 14; 4 mA in 6; 5 mA in 7, and ≥5mA in 50 patients. On the 6th month examination, six patients (5 with high-grade tumor) had motor deficits. These patients had changes in MEP that exceeded critical threshold during monitoring. Receiver operating characteristic analysis revealed 2.5 mA ScMTh as the cut-off point for limb paresis after awakening and 6 months for the groups. CONCLUSIONS: Subcortical mapping with MEP monitoring helps to achieve safe wider resection. The optimal safe limit for SCMTh was determined as 2.5 mA. Provided that safe threshold values are maintained in MEP, surgeon may force the functional limits by lowering the SCMTh to 1 mA, especially in low-grade gliomas.

Long-term follow-up of young denim sandblasters in Turkey.

BACKGROUND: Denim sandblasting-induced silicosis is a recently identified occupational disease. AIMS: In this study, we aimed to evaluate pulmonary and radiological changes in the long-term follow-up of former denim sandblasters. METHODS: Ninety former denim sandblasters were followed from 2007 to 2018. Chest X-rays were evaluated according to the International Labour Organization (ILO) classification. Baseline and final data were compared. Silicosis prevalence, radiological progression and pulmonary dysfunction were evaluated. RESULTS: All of the sandblasters were men. Their mean age was 34 ± 5 years, mean follow-up time was 9 ± 2 years (mean time since initial exposure: 17 ± 2 years) and mean duration of exposure was 34 ± 25 months. Rates of radiological progression and decline in pulmonary during follow-up were 63% and 39%, respectively. During follow-up, all patients were diagnosed with silicosis. All workers who were ILO category 0 at baseline (n = 26, 29%) progressed to higher categories. The number of patients in Category 2 doubled and the number of patients in Category 3 increased by 2.5-fold. Eleven patients developed new large opacities and the number of patients with category C opacity increased from 4 to 13. Exposure time was an independent determinant of radiological progression (OR: 1.0, P = 0.036) and decline in pulmonary function (OR: 1.3, P = 0.019). CONCLUSIONS: The prevalence of silicosis in denim sandblasters increases steadily even after exposure is discontinued. Radiological progression was observed in a higher proportion of workers than a decline in lung function. Duration of exposure was the major determinant of disease progression in our study.

Evaluation of lung densitometric and volumetric changes in silicosis patients using three-dimensional software for multidetector CT and the relationship with profusion scores.

AIM: To evaluate the density and volume changes in the lungs of silicosis patients and their relationship with the disease severity classification of the International Labor Organization (ILO). MATERIALS AND METHODS: The multidetector computed tomography (CT) images of 44 patients diagnosed with silicosis and 32 controls that underwent thoracic CT due to trauma were evaluated. Patients with silicosis were divided into three categories according to the ILO classification. Data related to the total lung volume, total lung mean density, lung opacity score, percentage of lung high opacity, and mean density in the lower and upper lobes were obtained using three-dimensional (3D) software. RESULTS: There was no significant difference between the total lung mean densities of the silicosis and control groups (p=0.213); however, a significant difference was observed between the two groups in terms of the total lung volume (p<0.0001). According to the ILO classification, there was a significant difference between the disease severity categories in relation to the percentage of lung high opacity (p=0.000005). A strong correlation was detected between disease severity and high opacity percentage (p<0.0001, r=0.804). According to the ILO classification, there was also a significant difference between disease severity categories in terms of the lung opacity score (p=0.000144), as well as a moderate correlation between disease severity and opacity score (p<0.0001, r=0.580). CONCLUSION: Total lung volume is a CT finding that shows variation in exposure to crystalline silica. The percentage of high opacity determined using multidetector CT is an effective parameter in evaluating disease severity.

Evaluation of serum ischaemia-modified albumin levels in patients with Bell's palsy.

OBJECTIVE: This prospective study aimed to evaluate the relationship between serum ischaemia-modified albumin levels and Bell's palsy severity. METHODS: The study included 30 patients diagnosed with Bell's palsy and 30 healthy individuals. The patients were separated into three disease severity groups (grades 2, 3 and 4) according to House-Brackmann classification. Blood samples were collected from all participants and the results compared between groups. RESULTS: Significant differences in serum ischaemia-modified albumin were found between the study and control groups (p < 0.001); values were significantly higher in the study group than in the control group. CONCLUSION: The significantly higher levels of serum ischaemia-modified albumin in the study group suggest that Bell's palsy pathogenesis is associated with oxidative stress.

Female workers' silicosis diagnosis delayed due to gender bias.

After excluding alternative explanations, a silicosis diagnosis is based on the combination of appropriate silica exposure history and compatible clinical, radiological and occasionally pathological findings. Not taking appropriate occupational history by a physician may cause a misdiagnosis or underdiagnosis of silicosis. Herein, we present a female worker in a small-scale sandblasting factory who worked as a controller. Her silicosis diagnosis was established 10 years after her first symptoms, and she underwent invasive procedures due to a lack of inquiry about her occupational history. Gender bias may be one of the reasons that her occupational history was not taken.

Do Atmospheric Changes and the Synodic Lunar Cycle Affect the Development of Spontaneous Pneumothorax?

BACKGROUND: Pneumothorax is defined as air in pleural space. The etiology of spontaneous pneumothorax (SP) is still under investigation and, despite many studies, remains uncertain. The aim of this study was to investigate the effects of the lunar cycle and daily weather changes on SP development. METHODS: The data of patients admitted to our clinic with SP were analysed retrospectively. The daily atmospheric pressure, relative ratio of humidity and temperature in degrees Celsius of each day were obtained. The mean values for each day, from the first to the 29th day, of the synodic lunar cycle (SLC) were calculated for the five-year study period. The attacks were allocated to the appropriate day of an ideal 29-day SLC, irrespective of the calendar date. RESULTS: A total of 131 patients who were admitted to our hospital with SP (130 males and 1 female with an average age of 32.4±12.2) were included in this study. The number of patients with SP showed a statistically significant correlation with mean atmospheric pressure (p=0.005), relative humidity (p=0.007) and outdoor temperature (p=0.02) but not with the SLC. CONCLUSIONS: SP is significantly influenced by weather-related factors. Changes in atmospheric pressure, humidity and outdoor temperature had obvious effects on the development of SP. However, the SLC had no effect on SP.

An epidemic of silicosis among former denim sandblasters.

Sandblasting denim using silica has emerged as a new cause of silicosis in Turkey. Following the discovery of several cases of silicosis in (young) workers who used this process, the frequency and main occupational risk factors of silicosis among former denim sandblasters in the region of Erzurum (Turkey) were evaluated. Demographic characteristics and information on working conditions were obtained by questionnaire and interview. In addition, spirometry testing was performed and chest radiographs were evaluated according to International Labour Office (ILO) classification of pneumoconioses in 157 former denim sandblasters. All subjects were male, with a mean (range) age of 23 (15-44) yrs. They had worked for a mean (range) of 36 (1-120) months, starting employment at a 17 (10-38) yrs of age. Most subjects (83%) had respiratory symptoms, especially dyspnoea (52%) but also chest pain (46%). Radiological evidence of silicosis (ILO score 1/0 or higher) was present in 77 (53%) out of 145 subjects with interpretable chest radiographs. These subjects had lower forced expiratory volume in one second and forced vital capacity. The risk of silicosis correlated with seniority (i.e. working as a foreman), exposure duration and number of places of work. Considering the high prevalence rate of silicosis in such workplaces, further problems are inevitable in the future unless effective measures are taken.

Doppler ultrasound assessment and serum cancer antigen 125 in the diagnosis of ovarian tumors.

OBJECTIVE: To differentiate benign from malignant ovarian tumors based on sonographic detection of a solid component. METHOD: Sixty-three women with ovarian masses were evaluated preoperatively by gray scale and power/color Doppler ultrasonographic examination, with specific predefined criteria for the solid component. Sensitivity, specificity, and positive and negative predictive values were calculated and assessed against the histopathologic outcome. The contribution of cancer antigen (CA) 125 levels to the diagnostic accuracy was also assessed. RESULT: Sensitivity, specificity, and positive and negative predictive values were 100%, 95.2%, 91.3% and 100%, respectively, with two false-positive results. Had an elevated CA 125 level (>35 U/mL) been included in the malignancy criteria, the false-positive results would have been eliminated, giving an accuracy of 100%. CONCLUSION: Sonographic evaluation with predefined specific criteria for the detection of a solid tumor component is an accurate method of preoperative discrimination between benign and malignant ovarian tumors. A serum CA 125 assay may assist in eliminating false-positive results.

Unbiased estimation of tumor regression rates during chemoradiotherapy for esophageal carcinoma using CT and stereology.

SUMMARY. The purpose of the present study is to estimate tumor volumes of 10 patients with esophageal carcinoma on serial CT images that are obtained before and after chemoradiotherapy using a stereological method. In this study, tumor volume was measured using the Cavalieri method of modern design stereology with a combination of three separate stages. Firstly, detailed systematic series of axial CT images of 1-cm thickness were obtained throughout the whole tumor area of each subject and to magnify them all CT images were projected on a screen by overhead projector and then were marked by manually tracing the outline of areas with tumor on serial CT images that are projected onto the screen. Secondly these images were drawn on paper. Finally the images on paper were evaluated with a point-counting method. It was shown in a pilot study analyzed that 100 test points counted on about 6--8 serial slices through for esophagus wall, lumen and wall + lumen are sufficient to secure coefficient of error (CE) on the estimates of volumes as in this study. It was found that tumor volumes before and after radiotherapy for esophagus wall, lumen and wall + lumen was 10.34 cm(3), 1.15 cm(3) and 11.75 cm(3) before and 5.93 cm(3), 1.43 cm(3) and 7.65 cm(3) after radiotherapy, respectively. When only esophagus wall and lumen volumes or wall + lumen volumes before and after radiotherapy were statistically compared, the difference between either esophagus wall (P<0.01) and lumen (P<0.01) volumes or total volumes (P<.1) were significant. It is concluded that CT estimated tumor volumes may be helpful in both evaluating the clinical situation of patients and providing a simple index to assess the efficiency of therapy, prediction of tumor regression rate and minimizing the risk of chemoradiotherapy damage.

Usefulness of induced sputum and fibreoptic bronchoscopy specimens in the diagnosis of pulmonary tuberculosis.

We investigated the diagnostic value of induced sputum (IS) and bronchial lavage (BL) specimens in patients with suspected pulmonary tuberculosis who had negative spontaneous sputum specimens or who were unable to produce sputum spontaneously. IS specimens and BL specimens obtained using flexible fibreoptic bronchoscopy from 55 patients were evaluated for the presence of acid-fast bacilli (AFB) and cultured for Mycobacterium tuberculosis. Positive results were found with IS smear in 23 patients, BL smear in 26 patients, and IS or BL culture in 42 patients. Culture of BL specimens had a higher sensitivity than IS or BL smears or culture of IS specimens. The highest sensitivity rate was obtained with a positive BL or IS culture (86%). For early diagnosis (a positive IS or BL smear), the sensitivity was 57%. IS has a higher sensitivity rate than spontaneous sputum for the detection of tuberculosis, and fibreoptic bronchoscopy is useful for the early diagnosis of tuberculosis when AFB are not detected in spontaneous or induced sputum specimens.

Trichoptysis caused by intrapulmonary teratoma: computed tomography and magnetic resonance imaging findings.

We describe a 9-year-old child with a history of trichoptysis caused by intrapulmonary teratoma and we present the CT and MRI findings of the teratoma. A heterogeneous mass containing cystic and solid elements was detected on both CT and MRI scans. Histopathological examination confirmed the diagnosis of teratoma. Teratomas arising from lung parenchyma, as in this case, are extremely rare in childhood. In the thoracic region, the most common localization of teratomas is the anterior mediastinal compartment. We also discuss the CT and MRI findings and the differential diagnosis of teratomas.

Comparison of the efficacy of nebulised budesonide with parenteral corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease.

OBJECTIVE: To compare the efficacy and safety of nebulised budesonide and systemic corticosteroid in the treatment of acute exacerbations of chronic obstructive pulmonary disease (COPD). DESIGN: Randomised, double-blind, placebo-controlled, parallel-group trial. PATIENTS AND INTERVENTIONS: A total of 40 patients who had moderate to severe acute exacerbations of COPD and required hospitalisation were enrolled in the study. The patients were randomised to receive either nebulised budesonide 8mg daily (n = 21) or systemic (intravenous) prednisolone 40mg daily (n = 19). Airway obstruction (peak expiratory flow rate [PEFR]) and gas exchange (arterial partial pressure of oxygen [PaO(2)] and carbon dioxide [PaCO(2)], pH and oxygen saturation [SaO(2)]) were evaluated at 30 min, at 6, 24 and 48 hours, and at day 10. RESULTS: There were no significant differences between groups at baseline. In both groups, differences were significant for PEFR, SaO(2) and PaO(2) (p < 0.001), but not for PaCO(2) and pH, in comparison with their baseline values. There were no significant differences between groups for all parameters (PEFR, PaO(2), PaCO(2), pH and SaO(2)) at all time periods. No adverse events were recorded in either group. CONCLUSIONS: Our study suggests that nebulised budesonide may be an alternative to parenteral corticosteroids in the treatment of acute exacerbations of COPD.

Evaluation of cerebral vasospasm with transcranial magnetic stimulation: an experimental study.

Despite the current use of several different methods for diagnosis and follow-up of cerebral vasospasm after subarachnoid hemorrhage, an easy, quick, reliable, and noninvasive method is still needed for evaluation of this entity. We investigated the value of transcranial magnetically evoked motor potential changes during the vasospasm period in a rabbit experimental subarachnoid hemorrhage model. We also recorded motor evoked potential changes after deferoxamine treatment during vasospasm. Our results reveal a significant increase in latency periods of evoked potentials during the angiographically proven vasospasm period (34.5%) over those in sham-operated rabbits (9.5%). With deferoxamine treatment, only a minor increase in latency periods (4.5%) was detected after subarachnoid hemorrhage. These results suggest the potential value of evoked motor potential recording as a diagnostic tool in cases of cerebral vasospasm.

Effects of deferoxamine and sympathectomy on endothelin-1-induced contraction and acetylcholine-induced relaxation following subarachnoid hemorrhage in carotid artery.

The role of endothelium-related factors in the pathogenesis of cerebral vasospasm after subarachnoid hemorrhage (SAH) has gained interest since the discovery of EDRF and of endothelin-1 (ET-1). The effect of SAH and both treatment of deferoxamine (DFO) and sympathectomy on endothelium-dependent vasodilation and ET-1-induced vasoconstriction of isolated rabbit carotid artery was examined using an isometric tension recording method. Thirty-five rabbits were divided into four groups: control animals, 7 days after SAH, treatment with DFO after SAH for 7 days and sympathectomy after SAH. Acetylcholine (10(-8) to 10(-5) M) was used to evoke concentration-dependent vasodilation of isolated arterial rings previously contracted by 10(-6) M phenylephrine. In the animals killed 7 days after SAH, acetylcholine-induced relaxation was suppressed and the degree of relaxation of this group was 50% of the initial contractile tone in response to the 10(-5) M acetylcholine. These relaxant responses did not return to control values in carotid arteries obtained from animals treated with DFO and subjected to sympathectomy. In isolated carotid arteries, ET-1 (10(-10) to 10(-8) M) produced concentration-dependent contractions. These contractile responses were significantly enhanced in animals 7 days after SAH compared with controls and did not return to control values in carotid arteries obtained from animals both treated with DFO and sympathectomized for 7 days after SAH. The present experiments suggest that impairment of endothelium-dependent vasodilation and the hyperreactivity of ET-1 of the carotid artery as well as cerebral arteries may be involved in the pathogenesis of cerebral vasospasm. Both treatment with DFO and sympathectomy during the chronic stage for vasospasm after SAH did not affect these vascular responses of the extradural part of the carotid artery to ET-1 and acetylcholine.

Effect of deferoxamine and sympathectomy on vasospasm following subarachnoid hemorrhage.

We examined the effects of subarachnoid hemorrhage (SAH) and treatment with deferoxamine (DFO) or sympathectomy on vascular smooth muscle function, as well as the underlying mechanisms involved, by recording the responses to nor-adrenaline and serotonin in isolated carotid arteries in vitro. All studies were performed before and 7 days after SAH. An experimental subarachnoid hemorrhage model was created in rabbits by injecting autologous arterial blood into the subarachnoid space of the rabbits via cisterna magna punction. During the chronic stage of vasospasm following SAH deferoxamine (DFO) was given to the animals and cervical and periarterial sympathectomy was performed in the other groups of animals. In isolated carotid arteries noradrenaline (10(-8) to 10(-4) mol/l) and serotonin (10(-8) to 10(-4) mol/l) produced concentration-dependent contractions. These contractile responses were significantly enhanced in animals 7 days after SAH compared to controls and did not return to control values in carotid arteries obtained from animals treated with DFO or sympathectomy for 7 days after SAH. These results show that SAH causes supersensitivity in the carotid as well as cerebral arteries during the first week after SAH and could contribute to the development of cerebral vasospasm. Both treatment with DFO and sympathectomy after SAH did not reduce the contractile responses to noradrenaline and serotonin in the carotid arteries. In conclusion, treatment with DFO or sympathectomy during the chronic stage of vasospasm after SAH did not affect the vascular responses of the extradural part of the carotid artery to vasoactive substances.