Lung transplantation in Turkey: lessons from surgeons and pulmonologists.

BACKGROUND/AIM: In order to actualize an efficient lung transplantation program, it is necessary to determine priorities and set up strategies. This study aimed to estimate the present situation in Turkey by determining the level of interest and knowledge of pulmonologists and thoracic surgeons regarding lung transplantation. MATERIALS AND METHODS: A questionnaire was prepared to establish the level of interest and knowledge of physicians on lung transplantation. It was sent to 2131 pulmonologists and thoracic surgeons, and 130 physicians completed the questionnaire. RESULTS: Of the 130 physicians who responded, 42 were thoracic surgeons and 88 were pulmonologists. There was no significant difference between the two groups regarding the availability of lung transplantation at their hospitals. The rates of correct answers to the questions and responses supporting the transplant initiative were higher in the thoracic surgeon group than in the pulmonologist group. CONCLUSION: The establishment of a successful system for lung transplantation in Turkey requires an increase in interest, knowledge, and dedication of physicians, coupled with adequate and continuous training. There also needs to be sufficient equipment and financing in addition to disciplined multidisciplinary teams and cooperation. This survey shows there is still much work to be done to achieve success in lung transplantation in Turkey.

Should Low-Molecular-Weight Heparin be Preferred Over Unfractionated Heparin After Thrombolysis for Severity Pulmonary Embolism?

PURPOSE: The role of low-molecular-weight heparin (LMWH) in managing nonmassive pulmonary embolism (PE) is well known. In unstable cases, especially after thrombolytic therapy for massive PE, unfractionated heparin (UFH) is preferred for PE management. This study aimed to investigate the effectiveness and safety of LMWH after thrombolytic therapy. METHODS: A prospective, observational multicenter trial was performed in 249 patients with acute PE who required thrombolysis. Massive and submassive PEs were categorized into 2 groups depending on whether they were treated with LMWH or UFH after thrombolytic treatment. The primary end point was all-cause mortality during the first 30 days; the secondary end point included all-cause mortality, nonfatal symptomatic recurrent PEs, or nonfatal major bleeding. RESULTS: The mean age at diagnosis was 60.7 ± 15.5 years. The PE severity was massive in 186 (74.7%) patients and submassive in 63 (25.3%). The incidence of all-cause 30-day death was 8.2% and 17.3% in patients with LMWH and UFH, respectively (P = .031). Major hemorrhage occurred in 4% (n = 5) and 7.9% (n = 10) of patients and minor hemorrhage occurred in 9% (n = 11) and 13.4% (n = 17) of the cases treated with LMWH and UFH, respectively. CONCLUSION: These results suggest that LMWH treatment can be used safely in patients with PE after thrombolytic therapy.

History of Lung Transplantation.

History of lung transplantation in the world can be traced back to the early years of the 20th century when experimental vascular anastomotic techniques were developed by Carrel and Guthrie, followed by transplantation of thoracic organs on animal models by Demikhov and finally it was James Hardy who did the first lung transplantation attempt on human. But it was not until the discovery of cyclosporine and development of better surgical techniques that success could be achieved in that field by the Toronto Lung Transplant Group led by Joel Cooper. Up to the present day, over 51.000 lung transplants were performed in the world at different centers. The start of lung transplantation in Turkey has been delayed for various reasons. From 1998 on, there were several attempts but the first successful lung transplant was performed at Sureyyapasa Hospital in 2009. Today there are four lung transplant centers in Turkey; two in Istanbul, one in Ankara and another one in Izmir. Three lung transplant centers from Istanbul which belong to private sector have newly applied for licence from the Ministry of Health.

Combination and comparison of two models in prognosis of pulmonary embolism: results from TUrkey Pulmonary Embolism Group (TUPEG) study.

BACKGROUND: Clinical parameters, biomarkers and imaging-based risk stratification are widely accepted in pulmonary embolism(PE). The present study has investigated the prognostic role of simplified Pulmonary Embolism Severity Index (sPESI) score and the European Society of Cardiology (ESC) model. METHODS: This prospective cohort study included a total of 1078 patients from a multi-center registry, with objectively confirmed acute symptomatic PE. The primary endpoint was all-cause mortality during the first 30days, and the secondary endpoint included all-cause mortality, nonfatal symptomatic recurrent PE, or nonfatal major bleeding. RESULTS: Of the 1078 study patients, 95 (8.8%) died within 30days of diagnosis. There was no significant difference between non-low-risk patients ESC [12.2% (103 of 754;)] and high-risk patients as per the sPESI [11.6% (103 of 796)] for 30-day mortality. The nonfatal secondary endpoint occurred in 2.8% of patients in the the sPESI low-risk and 1.9% in the ESC low-risk group. Thirty-day mortality occurred in 2.2% of patients the sPESI low-risk and in 2.2% the ESC low-risk group (P=NS). In the present study, in the combination of the sPESI low-risk and ESC model low-risk mortality rate was 0%. CONCLUSIONS: The sPESI and the ESC model showed a similar performance regarding 30-day mortality and secondary outcomes in the present study. However, the combination of these two models appears to be particularly valuable in PE.

Comparison of tuberculin skin testing and QuantiFERON-TB Gold-In Tube test in health care workers.

The purpose of this prospective, cross-sectional observational study was to compare the tuberculin skin testing (TST) with QuantiFERON-TB Gold-In Tube (QTF-GIT) for the detection of latent tuberculosis infection in healthcare workers (HCWs). The study included 78 volunteers who are HCWs at the same tertiary care teaching hospital for chest diseases and tuberculosis. Participants with active tuberculosis, immunodefficiency or malnutrition were not included. The TST was administered by the Mantoux method. Peptides representing ESAT-6, CFP-10 and TB7-7 were used as TB-specific antigens in the whole-blood Interferon-gamma (IFN-g) assay (QTF-GIT). There was a statistically significant relation between the number of Bacillus Calmette-Guerin (BCG) scars and the diameter of TST (p< 0.01). QTF results according to previous BCG vaccinations did not significantly differ (p> 0.05). There was an intermediate concordance between two tests (k: 0.346). QTF-GIT has a sensitivity of 56.14% (both TST and QTF-GIT are positive), specificity of 90.48% (both TST and QTF-GIT are negative); positive predictive value of 94.12% and negative predictive value of 43.18% and accuracy is 65.38%. There was a statistically significant relation between TST diameter and QTF result (p< 0.01). Latent tuberculosis infection prevalance of our study population was 43% according to QTF-GIT test, 73% according to TST and BCG vaccination rate was 87%. In conclusion, TST is affected by previous BCG vaccinations, QTF-GIT is not. We can recommend QTF-GIT test for the detection of latent tuberculosis infection as an alternative to TST in populations with routine BCG vaccination programme.

The evaluation of the Quantiferon-TB Gold test in pulmonary and extrapulmonary tuberculosis.

In our study we evaluated the Quantiferon-TB Gold (QFT-G) test and compared it with tuberculin skin test (TST) positivity in 44 pulmonary and 21 extrapulmonary tuberculosis cases in whom active tuberculosis infection was suspected on clinical, microbiologic and radiologic grounds. QFT-G positivity was 75% in pulmonary tuberculosis and 76.2% in extrapulmonary tuberculosis. TST positivity was 68.2 and 62%, respectively. Although QFT-G positivity was higher than TST positivity, the difference was statistically insignificant (P=0.77). Similar to TST, QFT-G is one of the supplementary diagnostic tests for active tuberculosis disease and latent tuberculosis infection. Its advantage over TST is that it gives a result on the same day and it is unaffected by prior BCG and previous exposure to atypical mycobacteria. In conclusion, we think that, as with TST, a positive QFT-G result can be an adjunct to diagnosis in patients having clinical and radiological data compatible with tuberculosis.

A clinical dilemma: abdominal tuberculosis.

AIM: To evaluate the clinical, radiological and microbiological properties of abdominal tuberculosis (TB) and to discuss methods needed to get the diagnosis. METHODS: Thirty-one patients diagnosed as abdominal TB between March 1998 and December 2001 at the Gastroenterology Department of Kartal State Hospital, Istanbul, Turkey were evaluated prospectively. Complete physical examination, medical and family history, blood count erythrocyte sedimentation rate, routine biochemical tests, Mantoux skin test, chest X-ray and abdominal ultrasonography (USG) were performed in all cases, whereas microbiological examination of ascites, upper gastrointestinal endoscopy, colonoscopy or barium enema, abdominal tomography, mediastinoscopy, laparoscopy or laparotomy were done when needed. RESULTS: The median age of patients (14 females,17 males) was 34.2 years (range 15-65 years). The most frequent symptoms were abdominal pain and weight loss. Eleven patients had active pulmonary TB. The most common abdominal USG findings were ascites and hepatomegaly. Ascitic fluid analysis performed in 13 patients was found to be exudative and acid resistant bacilli were present in smear and cultured only in one patient with BacTec (3.2 %). Upper gastrointestinal endoscopy yielded nonspecific findings in 16 patients. Colonoscopy performed in 20 patients showed ulcers in 9 (45 %), nodules in 2 (10 %) and, stricture, polypoid lesions, granulomatous findings in terminal ileum and rectal fistula each in one patient (5 %). Laparoscopy on 4 patients showed dilated bowel loops, thickening in the mesentery, multiple ulcers and tubercles on the peritoneum. Patients with abdominal TB were divided into three groups according to the type of involvement. Fifteen patients (48 %) had intestinal TB, 11 patients (35.2 %) had tuberculous peritonitis and 5 (16.8 %) tuberculous lymphadenitis. The diagnosis of abdominal TB was confirmed microbiologically in 5 (16 %) and histo-pathologically in 19 patients (60.8 %). The remaining nine patients (28.8 %) had been diagnosed by a positive response to antituberculous treatment. CONCLUSION: Neither clinical signs, laboratory, radiological and endoscopic methods nor bacteriological and histopathological findings provide a gold standard by themselves in the diagnosis of abdominal TB. However, an algorithm of these diagnostic methods leads to considerably higher precision in the diagnosis of this insidious disease which primarily necessitate a clinical awareness of this serious health problem.