Diaphragmatic ultrasonography in patients with IPF: Is diaphragmatic structure and mobility related to fibrosis severity and pulmonary functional changes?

Introduction: There is evidence to suggest that dyspnea and impaired exercise capacity are associated with respiratory muscle dysfunction in idiopathic pulmonary fibrosis (IPF) patients. We aimed to evaluate the functions of the diaphragm with ultrasonography (US) and to determine the correlation of the data obtained with the pulmonary function parameters of the patients, exercise capacity, and the extent of fibrosis radiologically. Materials and Methods: Diaphragmatic mobility, thickness, and thickening fraction (TF) were measured by ultrasonography in IPF patients and the control group. The correlation between these measurements, pulmonary function tests (PFT), six-minute walking test (6MWT), mMRC score, and total fibrosis score (TFS) was evaluated. Result: Forty-one IPF patients and twenty-one healthy volunteers were included in the study. No difference was found between the patient and control groups in diaphragmatic mobility during quiet breathing (QB) on ultrasound (2.35 cm and 2.56 cm; p= 0.29). Diaphragmatic mobility during deep breathing (DB) was found to be lower in the patient group when compared to the control group (5.02 cm and 7.66 cm; p<0.0001). Diaphragmatic thickness was found to be higher during QB and DB in IPF patients (0.33 cm and 0.31 cm, p= 0.043; 0.24 cm and 0.22 cm, p= 0.045). No difference was found between the two groups in terms of thickening fraction (39.37%, 44.16%; p= 0.49). No significant correlation was found between US measurements and PFT, 6MWT, mMRC score, and TFS in IPF patients (p> 0.05). Conclusions: The functions of the diaphragm do not appear to be affected in patients with mild-to-moderate restrictive IPF. This study showed that there was no relationship between diaphragmatic functions and respiratory function parameters and the extent of fibrosis. Further studies, including advanced stages of the disease, are needed to understand the changes in diaphragmatic functions in IPF and to determine whether this change is associated with respiratory function parameters and the extent of fibrosis.

Comparison of clinical outcomes in idiopathic pulmonary fibrosis patients with and without hiatal hernia.

Introduction: Idiopathic pulmonary fibrosis (IPF) is a progressive disease of unknown etiology with an unpredictable course. We aimed to investigate the effects of the presence of hiatal hernia (HH) and its consequences on the clinical manifestation of IPF. Materials and Methods: Patients diagnosed with IPF with or without hiatal hernia were retrospectively compared in terms of clinical findings, total fibrosis scores (TFS), and lung function in the interstitial lung diseases (ILD) outpatient clinic. Result: A total of 142 IPF patients were included in the study. HH was detected in 62.7% (n= 89) of the patients. There was no statistically significant difference between IPF patients with or without HH in terms of age, gender, smoking history, and anti-reflux drug use (p> 0.05). There was no statistically significant difference between IPF patients with or without HH in terms of symptoms such as dyspnea, cough, regurgitation, heartburn, nausea, dysphagia, chest pain, and hoarseness (p> 0.05). In addition, no statistically significant difference was found between IPF patients with or without HH in terms of mortality rate, survival time after diagnosis, and exacerbations (p> 0.05). Six-minute walking distance and SpO2 change, percentage of predicted forced vital capacity (FVC) value, and percentage of predicted diffusing capacity for carbon monoxide (DLCO) value did not differ significantly between the groups (p> 0.05). There was no statistically significant difference between the groups in terms of total fibrosis score (p= 0.668). Conclusions: According to the results of this study, 62.7% (n= 89) of IPF patients had HH, and there was no difference in clinical outcomes, TFS, and pulmonary functions between IPF patients with or without HH.

The Comparison Between Non-High Risk Patients with and Without Cancer Diagnosed with Pulmonary Embolism.

OBJECTIVE: This study aimed to compare the pulmonary embolism (PE) location and clot burden on computed tomography pulmonary angiography (CTPA), the degree of right ventricular dysfunction (RVD), D-dimer, and cardiac troponin I (cTnI) levels, and the presence of a lower extremity deep venous thrombosis (DVT) in patients with and without cancer diagnosed with a non high risk pulmonary embolism (PE). METHOD: We calculated Miller score for each patient for clot burden. The location of PE was also evaluated at CTPA. D-dimer and cardiac cTnI levels were measured. Patients had echocardiography for RVD and lower extremity color flow Doppler ultrasonography for DVT. RESULTS: The study included 71 patients with PE. The patients were divided into two groups according to the presence of cancer. There was no statistically significant difference for D-dimer levels (P=0.15), PE location (p=0.67), clot burden (P=0.34), RVD (P=0.28) and DVT (P=0.33) between groups (P=0.15). Cancer patients diagnosed as PE had statistically significantly higher levels of cTnI than those who were diagnosed as PE without cancer (P=0.03). CONCLUSION: There was no significant difference between patients diagnosed as PE with and without cancer in terms of D-dimer levels, clot burden and emboli location, RVD and DVT. cTnI levels were higher in non-high risk PE patients with cancer than these patients without cancer.

Carotid intima-media thickness in chronic obstructive pulmonary disease and survival: A multicenter prospective study.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is associated with increased cardiovascular morbidity and mortality. Carotid intima-media thickness (CIMT) is a noninvasive method assessing atherosclerosis. OBJECTIVE: It was aimed to determine relationship and survival between COPD and CIMT. METHODS: CIMT was measured using Doppler ultrasound (USG) in 668 stable COPD patients at 24 centers. Patients were followed-up for 2 years. RESULTS: There were 610 patients who completed the study. There were 200 patients CIMT with <0.78 mm (group 1), and 410 with CIMT ≥ 0.78 mm (group 2). There was a significant difference at the parameters of age, gender, smoking load, biomass exposure, GOLD groups and degree of airway obstruction (FEV1) between groups 1 and 2. Our results revealed positive correlations between mean CIMT and age, smoking load (pack-years), biomass exposure (years), exacerbation rate (last year), duration of hypertension (years) and cholesterol level; negative correlations between CIMT and FEV1 (P < 0.05). According to logistic regression model, compared with group A, risk of CIMT increase was 2.2-fold in group B, 9.7-fold in group C and 4.4-fold in group D (P < 0.05). Risk of CIMT increase was also related with cholesterol level (P < 0.05). Compared with infrequent exacerbation, it was 2.8-fold in the patients with frequent exacerbation (P < 0.05). The mean survival time was slightly higher in group 1, but not significant (23.9 vs 21.8 months) (P > 0.05). CONCLUSION: This study is the first regarding CIMT with combined GOLD assessment groups. It has revealed important findings supporting the increase in atherosclerosis risk in COPD patients. We recommend Doppler USG of the carotid artery in COPD patients at severe stages.

Desquamative interstitial pneumonia: Risk factors, laboratory and bronchoalveolar lavage findings, radiological and histopathological examination, clinical features, treatment and prognosis.

Desquamative interstitial pneumonia is a type of smoking-associated major idiopathic interstitial pneumonia, which is characterized by accumulation of alveolar macrophages in alveolar lumens and septa and develops secondary to mainly active or passive exposure to cigarette smoke. Desquamative interstitial pneumonia mostly occurs in male smokers in association with non-specific symptoms responsive to steroid therapy and has a better prognosis than usual interstitial pneumonia. To date, no large-scale clinical studies have been performed on desquamative interstitial pneumonia patients. Factors responsible for the scarcity of data on the clinical course of this condition include the retrospective nature of the available information as well as its rare occurrence. Despite this, a general consensus exists as to the nature of its symptoms, association with smoking, age and gender distribution, findings of respiratory function tests, steroid responsivity and mortality. The objective of the present review article was to report on desquamative interstitial pneumonia and to describe its etiology, risk factors and clinical features, as well as the laboratory, bronchoalveolar lavage, radiological and histopathological findings, and the treatment and prognosis of affected patients.

[Bronchial thermoplasty for asthma treatment]. / Astim tedavisinde bronsiyal termoplasti.

New asthma therapies such as omalizumab, mepolizumab and reslizumab are used according to the inflammatory phenotype, but there are many patients with asthma which are not suitable for these therapies or do not improve with these therapies. Bronchial thermoplasty (BT) was approved by FDA for the treatmet of adults with severe asthma and uncontrolled symptoms despite treatment with inhaler corticosteroids (ICS) and long-acting bronchodilators in 2010. BT is a minimally invasive bronhoscopic intervention based on radiofrequency energy delivery to the larger airways to reduce excessive airway smooth muscle mass. BT has been shown to be effective at reducing asthma exacerbations and improving asthma control for patients with severe asthma. BT is safe for 5 years after BT in patients with severe refractory asthma. BT may be primarily preferred for patients with nonallergic, non-eosinophilic (non-TH2) severe asthma not improving with standart treatments. Unfortunately, the mechanism of action of BT is incompletely understood. Uncertainty remains how to identify patients who will responde to this intervention. Several studies are underway that may show the place of BT in severe asthma and identify responders. There is also a need for studies comparing BT with other treatment options. This review will provide an overwiew of BT. We will discuss the latest evidence on the use of BT in asthma, patient selection criteria and performing the procedure will be reviewed.

Hepatitis C and pulmonary fibrosis.

Hepatitis C is one of the most important infectious agents worldwide. There are conflicting results regarding the relationship between pulmonary fibrosis and hepatitis C. It is thought that hepatitis C may play a role in the development or exacerbations of idiopathic pulmonary fibrosis, but no clear link between hepatitis C and pulmonary fibrosis development has been demonstrated yet to date. In the recent era, indirect effects of hepatitis C rather than a direct effect are more suspected on pulmonary fibrosis. These indirect effects could also been documented only by a few case-based studies.

Relation between inflammatory cytokine levels in serum and bronchoalveolar lavage fluid and gene polymorphism in young adult patients with bronchiectasis.

AIM: Bronchiectasis develops as a result of genetic and environmental factors and its etiopathogenesis is not still clear. Recent studies have revealed that inflammatory cytokines, which are formed as a result of chronic infection and inflammation, play a role in the pathogenesis of bronchiectasis. For this purpose, the level of inflammatory cytokines in bronchiectasis and the presence or absence of a genetic predisposition with the gene polymorphism of these cytokines was investigated. MATERIAL AND METHODS: A total of 60 patients, 40 study cases and 20 controls, which were monitored with the diagnosis of bronchiectasis were included in the study. In these individuals, cytokine levels [interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor (TNF)-α] in serum and bronchoalveolar lavage (BAL) fluid, along with the routine blood tests, were determined. Furthermore, the polymorphism in IL-6, IL-8, IL-10, and TNF-α cytokine genes and its frequency were studied in the obtained DNA by the automatic sequence analysis method and the results were compared. FINDINGS: It was found that in serum and BAL fluid of the patient group, the IL-8 level was high, whereas the IL-10 level was low (P<0.05). No significant difference was detected in the other cytokines (P>0.05). It was found that in cytokine gene polymorphisms IL-8 -251 A/T, IL-10 -592 A/C, and IL-10 -819 T/C genotypes are associated with increased risk of bronchiectasis. It was detected that the IL-8 -251 A/T genotype increased the risk of having the disease by 4.19 fold. (OR =4.19, 95% CI =1.24-14.17, P=0.021). The IL-10 -592 C/A genotype increased the risk of having the disease by 5.71 fold (OR = 5.71, 95% CI =1.35-24.06, P=0.017) and the IL-10 -819 T/C genotype increased the risk of having the disease by 5.06 fold (OR =5.06, 95% CI =1.20-21.27, P=0.048). No significant correlation was found between the other polymorphisms and bronchiectasis. CONCLUSIONS: The IL-8, IL-10 levels and the gene polymorphism of these cytokines differ. In addition to detecting higher levels of pro-inflammatory IL-8 and lower levels of anti-inflammatory IL-10, detection of gene polymorphism related to these two cytokines in bronchiectasis gives rise to the thought that cytokines may have role in a predisposition to bronchiectasis. However, as the number of patients is small, precise remarks could not be made on this subject. There is need for further studies include a larger number of patients.

[Venous thromboembolism and cancer]. / Venöz tromboembolizm ve kanser.

Venous thromboembolism (VTE) is one of the complications which have significant influence on mortality in patient with cancer. Early mortality rate is high in cancer patients who have VTE. This complication is related with cell type and stage of the cancer, surgery applied during cancer treatment, applying catheter and the chemotherapeutic agents. VTE prophylaxis and/or treatment in treatment and follow-up of cancer patients will provide a reduction in mortality and morbidity rates. VTE prophylaxis and treatment poses differences according to both treatment approaches which will be applied and the type of cancer. It has been aimed to describe pathogenesis, risk factors and treatment approaches taking into account international consensus reports in this review.

Evaluation of quality of life with the chronic obstructive pulmonary disease assessment test in chronic obstructive pulmonary disease and the effect of dyspnea on disease-specific quality of life in these patients.

PURPOSE: The chronic obstructive pulmonary disease (COPD) assessment test (CAT) was recently introduced for use in assessing disease-specific quality of life and follow-up of patients with COPD. The purpose of this study was to evaluate the effect of the dyspnea on disease-specific quality of life detected by CAT score in patients with COPD. MATERIALS AND METHODS: In this study, 90 stable patients with COPD as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria were included. The level of dyspnea was assessed with the Medical Research Council (MRC) dyspnea scale, and disease-specific quality of life was assessed with CAT score. RESULTS: The mean ± SD age was 68.5 ± 10.9 (range 41-97) years. A significant relationship was established between CAT score, MRC dyspnea scale score and GOLD stage in patients with COPD. There was also a positive correlation between dyspnea scale scores and GOLD stage in the patients (p<0.001), as well as positive correlation between CAT score and dyspnea scale score (p<0.001). CAT score showed a significant correlation with hospitalization and exacerbations (p<0.05). CONCLUSION: Dyspnea is an important symptom that may impact quality of life in patients with COPD. CAT was shown to be a simple, fast and intelligible measurement of disease-specific quality of life, and was correlated with levels of dyspnea in patients with COPD.

Angiopoietin 2 levels in serum and bronchial lavage fluids and their relationship with cancer stages in lung cancer patients.

BACKGROUND: Angiopoietin 2 (Ang-2) has an important role in tumor angiogenesis. In this study, Ang-2 levels of serum and bronchioloalveolar lavage fluids (BALF) in patients with lung cancer were measured and correlated with clinical and biochemical parameters. METHODS: Thirty-five cases newly diagnosed with lung cancer and 18 controls with non-cancerous lung diseases were included in the study. Tumor histology, staging, metastasis, tumor markers, biochemical and clinical parameters were all recorded. RESULTS: Serum Ang-2 levels were significantly higher in the lung cancer group compared to the control (lung cancer median: 2.42 ng/mL [2.19-2.98], control 0.67 [0.31-1.10]; P < 0.001), whereas Ang-2 levels in BALF were lower in the lung cancer group compared to the control (lung cancer median 0.41 ng/mL [0.22-0.79], control 0.67 [0.46-1.03]; P = 0.02). In the cancer group, higher serum Ang-2 levels (r = 0.52, P < 0.001) were associated with the stage of cancer. No significant correlation was observed between BALF Ang-2 levels and non-small cell lung cancer stages and small-cell lung cancer advanced stage (P = 0.793, r = 0.07). Serum Ang-2 levels were significantly higher in distant metastasis (M1) versus no distant metastasis (M0) (M1: 2.57 ng/mL [2.38-2.87], M0: 2.22 [1.49-2.40], P = 0.01). No significant correlation was observed between BALF Ang-2 levels and M1 (r = 0.11, P = 0.53). CONCLUSIONS: Serum Ang-2 levels were significantly higher in lung cancer patients and positive correlations were observed between serum Ang-2, tumor stage, and metastasis.

[Current approach to respiratory problems in neuromuscular diseases]. / Nöromusküler hastaliklardaki solunumsal problemlere güncel yaklasim.

Neuromuscular diseases lead to respiratory failure as they cause progressive weakness of the muscle of respiration. Studies show that noninvasive mechanical ventilation improves symptoms, gas exchange, quality of life, and survival in these patients. Noninvasive mechanical ventilation should be use at the onset of nocturnal hypoventilation. Airway clearance therapy is very important in these patients. The combination of noninvasive mechanical ventilation with cough-assist techniques decreases pulmonary morbidity and hospital admissions. Invasive mechanical ventilation is indicated for patients who require continuous mechanical ventilation for longer than a few days, or those who have contraindications to noninvasive mechanical ventilation. Diaphragmatic pacemakers may be a treatment option in patients with high spinal cord injuries. Episodes of acute respiratory failure in neuromuscular diseases are precipitated by respiratory infections. Management of episodes of acute respiratory failure may require endotracheal intubation.

[Tuberculosis incidence and primary drug resistance rates in young soldiers: data from 14 military hospitals in Turkey]. / Genç Askerlerde Tüberküloz Insidansi ve Primer Ilaç Direnci Oranlari: Ülkemizdeki 14 Asker Hastanesinin Verileri.

Tuberculosis is an important health care problem worldwide as well as in Turkey and the control programmes are still in progress. Epidemiological data are necessary to conduct control studies related to the disease. Tuberculosis incidence and drug resistance rates are two necessary parameters which should be monitored for the effective establishment of tuberculosis control. In this objective, tuberculosis incidence and drug resistance rates were studied in young subjects performing their compulsory military service in Turkish Armed Forces. The study was performed in 14 military hospitals which served for the country-wide soldier patients. Based on the computerized medical database of these military hospitals, conscripts diagnosed with tuberculosis between January 01, 2009 and December 31, 2009 were retrospectively evaluated. Drug sensitivity tests of the Mycobacterium tuberculosis complex isolates were done prior to the treatment in the two military medical training hospitals of the two big cities of Turkey (Ankara and Istanbul). There were a total of 259 new tuberculosis cases in 2009 and they were all male with a mean age of 22.51 ± 4.63 years. The number of patients with pulmonary, extrapulmonary (pleuresia, lymphadenitis, others) and both pulmonary and extrapulmonary involvements were 175 (67.5%), 72 (27.8%) and 12 (4.6%), respectively. The total rate of pulmonary tuberculosis cases was 72.2% (187/259) and 64.7% (121/187) of them were smear positive. Since the number of soldiers in Turkish army in the midyear was 537.200; total tuberculosis, pulmonary tuberculosis and smear-positive pulmonary tuberculosis incidences were estimated as 48.2/100.000, 34.8/100.000 and 22.5/100.000, respectively. Drug sensitivity tests was performed for the M.tuberculosis complex strains isolated from 104 cases. Primary resistance rate to at least one drug was detected as 16.3% (n= 17), while the rates of resistance for isoniazid, rifampicin, ethambutol and streptomycin were 12.5% (n= 13), 7.7% (n= 8), 5.8% (n= 6) and 0.9% (n= 1), respectively. Multidrug resistant tuberculosis (isoniazid + rifampicin resistance) was detected in 6 (5.8%) patients. Our data indicated that although tuberculosis incidence among young soldiers was moderately high, a decreasing trend was observed when compared to the previous years. However, the rates of primary anti-tuberculosis drug resistance and multi-drug resistance were found to be high in our study. To decrease the incidence of tuberculosis and multidrug resistant tuberculosis, drug sensitivity tests should be performed for each patient and national tuberculosis programme should be established effectively.

[Case report: Löffler's syndrome due to Ascaris lumbricoides mimicking acute bacterial community--acquired pneumonia]. / Olgu sunumu: akut bakteriyel toplum kökenli pnömoni klinigini taklit eden Ascaris lumbricoides'e bagli bir Löffler's sendromu.

In this study we present a patient with Loeffler's syndrome caused by Ascaris lumbricoides who presented with the clinical findings of community-acquired pneumonia (CAP). Our patient, who was twenty-five years old, and who had had symptoms such as coughing, expectorating, dyspnea and fever for approximately ten days, was hospitalized. We auscultated polyphonic rhonchuses at the both hemithoraxes. A chest X-ray revealed bilateral lower zone patch consolidation. Acute bacterial community acquired pneumonia (CAP) was diagnosed due to these findings and empirical antibiotic treatment was begun. Repeated sputum Gram stains were negative, and both sputum and blood cultures were sterile. A sputum smear was negative for acid-fast bacilli. The patient's fever and respiratory complaint did not respond to the empirical antibiotics therapy. During the course of advanced investigations, we measured peripheric eosinophilia, and high levels of total Eo and total IgE, and observed Ascaris lumbricoides eggs during stool examination. The patient was given a diagnosis of Loeffler's syndrome. Thereupon the patient was treated successfully with one dose of albendazol 400 mg. In conclusion, we suggest that Loeffler's syndrome must be considered early in the differential diagnosis for CAP when peripheric eosinophilia is seen in patients if they live in an endemic area for parasitic disease.

[Affecting factors of nicotine dependence in the smoker health workers]. / Sigara içen saglik personelinde nikotin bagimlilik düzeyini etkileyen faktörler.

Nicotine dependence is pointed out as the first reason of smoking behavior continuity and treatment failure. We investigated the nicotine dependence level (NDL) of health workers and the factors which affect it. We carried out the Fagerstrom test for nicotine dependence (FTND) and a questionnaire composed of 24 questions that evaluate demographic characters and the smoker ideas about smoking on health workers who staff at the a training hospital in Istanbul. NDL was not related with sex, age, education, marital status, child number and working time in health area (p> 0.05). There was correlation between NDL and daily smoked cigarette number (r= 0.71, p< 0.001). There was an opposite relationship among initiation age, regular use age and NDL (in order r= -0.16 and p= 0.013, r= -0.25 and p< or =0.001). 30% of the cases who had high NDL were smoking in everywhere of their home (p< 0.001). They also had high smoking ratios near surroundings of nonsmoker people (p= 0.003). The cases who had high NDL did not want to quit smoking (p= 0.028). Working in a hospital increased smoking ratio in 41.77% cases and did not affect the NDL (p= 0.3). It was thought that the cases that had high NDL did not take into consideration their surroundings and did not want to quit smoking. Health workers should be considered as a target population during antismoking campaigns, in order to make them willing in the struggle against tobacco.

The course of serum adenosine deaminase levels in patients with pulmonary tuberculosis.

BACKGROUND: This study was done to investigate the course of serum adenosine deaminase (sADA) level during pulmonary tuberculosis (TB) and its relationship with clinical, radiological, and laboratory parameters in TB patients. MATERIAL/METHODS: sADA levels were measured at the beginning and after the first, second, and sixth months in 38 smear-positive TB patients. Chest X-rays were taken. Additionally, peripheral blood leukocyte and lymphocyte counts, erythrocyte sedimentation rate (ESR), and C reactive protein (CRP) levels were measured. Fifteen healthy persons were enrolled in the study as controls. RESULTS: The level of sADA at the beginning was 33.2+/-13.9 U/l in the patients and 19.0+/-7.1 U/l in controls. The specificity and sensitivity were found to be 100% and 42%, respectively. The level of sADA showed elevation (45.1+/-10.6 U/l) after one month and gradually decreased in the second (34.6+/-10.1 U/l) and sixth months (24.6+/-4.7 U/l). ANOVA (post hoc Bonferroni) showed a significant difference in sADA levels between the beginning and the first month (p=0.005), the first and second months (p=0.016), and between the first month and the end of treatment (p<0.001). There was also a significant difference between sADA level at the end of treatment and the control value (p=0.01). During these times there were significant differences in the radiological course, peripheral blood lymphocyte count, ESR, and CRP levels. CONCLUSIONS: sADA levels in TB patients showed a slight elevation in the first month, but it decreased during treatment in parallel with the effectiveness. This may have an association with lymphocytic activation.

Giant hamartoma originating from the chest wall in an adult.

Hamartomas of the chest wall are rare benign lesions usually appear in infancy. We report an adult with giant hamartoma of the chest wall. A 21-year-old man was admitted to the hospital with swelling on his scapular region. An erythematous, swollen, and wide plaque formed mass lesion of 250 x 180 on the left scapular region was found in his physical examination. Thorax CT revealed a tumoral lesion in left hemithorax wall with destruction of the 3rd rib, and formation of the new bone growing and asymmetry in thorax by infiltrating surrounding soft tissues, and decreased left lung volume. Pathological findings referred to soft tissue hamartoma. After the diagnosed, the patient underwent to thoracotomy.