ERS International Congress 2023: highlights from the Thoracic Surgery and Lung Transplantation Assembly.

Five sessions presented at the European Respiratory Society Congress 2023 were selected by Assembly 8, consisting of thoracic surgeons and lung transplant professionals. Highlights covering management of adult spontaneous pneumothorax, malignant pleural effusion, infectious and immune-mediated complications after lung transplantation, as well as the pro and con debate on age limit in lung transplantation and results of the ScanCLAD study were summarised by early career members, supervised by the assembly faculty.

Pulmonary Physician Consultancy in Emergency Services in Turkiye (PuPCEST) - a cross-sectional multicenter study.

Pulmonology is one of the branches that frequently receive consultation requests from the emergency department. Pulmonology consultation (PC) is requested from almost all clinical branches due to the diagnosis and treatment of any respiratory condition, preoperative evaluation, or postoperative pulmonary problems. The aim of our study was to describe the profile of the pulmonology consultations received from emergency departments in Turkiye. A total of 32 centers from Turkiye (the PuPCEST Study Group) were included to the study. The demographic, clinical, laboratory and radiological data of the consulted cases were examined. The final result of the consultation and the justification of the consultation by the consulting pulmonologist were recorded. We identified 1712 patients, 64% of which applied to the emergency department by themselves and 41.4% were women. Eighty-five percent of the patients had a previously diagnosed disease. Dyspnea was the reason for consultation in 34.7% of the cases. The leading radiological finding was consolidation (13%). Exacerbation of preexisting lung disease was present in 39% of patients. The most commonly established diagnoses by pulmonologists were chronic obstructive pulmonary disease (19%) and pneumonia (12%). While 35% of the patients were discharged, 35% were interned into the chest diseases ward. The majority of patients were hospitalized and treated conservatively. It may be suggested that most of the applications would be evaluated in the pulmonology outpatient clinic which may result in a decrease in emergency department visits/consultations. Thus, improvements in the reorganization of the pulmonology outpatient clinics and follow-up visits may positively contribute emergency admission rates.

Lung cancer from suspicion to treatment: An indicator of healthcare access in Turkey.

BACKGROUND: Lung cancer is the leading cause of cancer-related deaths worldwide. Before beginning lung cancer treatment, it is necessary to complete procedures such as suspecting lung cancer, obtaining a pathologic diagnosis, and staging. This study aimed to investigate the processes from suspicion of lung cancer to diagnosis, staging, and treatment initiation. METHODS: The study was designed as a multicenter and cross-sectional study. Patients with lung cancer from various health institutions located in all geographic regions of Turkey were included in the study. The sociodemographic and clinical characteristics of the patients, the characteristics of the health institutions and geographic regions, and other variables of the lung cancer process were recorded. The time from suspicion of lung cancer to pathologic diagnosis, radiologic staging, and treatment initiation, as well as influencing factors, were investigated. RESULTS: The study included 1410 patients from 29 different medical centers. The mean time from the initial suspicion of lung cancer to the pathologic diagnosis was 48.0 ± 52.6 days, 39.0 ± 52.7 days for radiologic staging, and 74.9 ± 65.5 days for treatment initiation. The residential areas with the most suspected lung cancer cases were highly developed socioeconomic zones. Primary healthcare services accounted for only 0.4% of patients with suspected lung cancer. The time to pathologic diagnosis was longer in the Marmara region, and the wait time for staging and treatment initiation was longer in Eastern and Southeastern Anatolia. Patients who presented to chest disease referral hospitals with peripheral lesions, those with early-stage disease, and those who were diagnosed surgically had significantly longer wait times. CONCLUSION: The time between pathologic diagnosis, staging, and treatment initiation in lung cancer was longer than expected. Increasing the role of primary healthcare services and distributing socioeconomic resources more equally will contribute to shortening the time to diagnosis and improve treatment processes for lung cancer.

Pulmonary Embolism in a Liver Donor: A Case Report and Review of the Literature.

Liver transplant is an important treatment option for end-stage liver disease, and living related donation is an option to shorten or eliminate the waiting period for the patients, especially when shortage of organs is of concern. It is crucial to provide optimal safety for the donors and to thoroughly examine them preoperatively in order to decrease perioperative and postoperative complications. Here, we report the case of a living donor who had undergone a left liver lobectomy and on postoperative day 2 presented with a radiologically severe pulmonary embolism, despite the absence of any risk factor for venous thromboembolism or pulmonary embolism. The patient was treated with tissue plasminogen activator and heparin infusions and was discharged 1 week later.

Can adipokines predict clinical prognosis and post-COVID lung sequelae?

BACKGROUND: Adipokines play an important role in the regulation of inflammatory responses toward infections, including COVID-19. This study aimed to investigate the role of chemerin, adiponectin, and leptin in prognosis and post-COVID lung sequelae in hospitalized patients with COVID-19. METHODS: Serum levels of the three adipokines were measured upon admission of polymerase chain reaction-confirmed patients with COVID-19 who were followed up for 6 months for the clinical outcome and lung sequelae formation. RESULTS: A total of 77 patients were included in the study. Of the 77 patients, 58.4% were males, and the median age was 63.2 ± 18.3 years. Fifty-one patients (66.2%) had a good prognosis. Among adipokines, only chemerin was significantly lower in the bad prognosis group (P < 0.05), and the serum levels showed a negative correlation with age (rho = -0.238; P < 0.05). Leptin levels were negatively correlated with gamma glutamyl transferase levels, which were significantly higher in the bad prognostic group (rho = -0.240; P < 0.05). Twenty-four patients had no lung sequelae, and 20 developed sequelae within 6 months after infection. Chemerin/adiponectin ratio with a cut-off value of 0.96 and an area under the curve 0.679 (P < 0.05) might predict the sequelae formation. CONCLUSIONS: Chemerin levels are lower, especially in patients with a bad prognosis, and the chemerin/adiponectin ratio might predict the development of lung sequelae in patients with COVID-19.

Interview with the ECM Award winner 2022 and introducing the new ECM members.

This article presents the interview with the ERS Early Career Member Awardee 2022 (@MathioudakisAG) and provides a brief introduction to the new ECM members https://bit.ly/3BSRgV2.

ERS International Congress 2022: highlights from the Thoracic Surgery and Lung Transplantation Assembly.

The thoracic surgery and lung transplantation assembly (Assembly 8) of the European Respiratory Society (ERS) is delighted to present the highlights from the 2022 ERS International Congress that took place in a hybrid version in Barcelona, Spain. We have selected the four main sessions that discussed recent advances across a wide range of topics including the effects of coronavirus disease 2019 on thoracic surgery and the challenges regarding lung transplantation in connective tissue diseases and common variable immunodeficiency. The sessions are summarised by early career members in close collaboration with the assembly faculty. We aim to provide the reader with an update and enhanced insight into the highlights of the conference in the fields of thoracic surgery and lung transplantation.

Has the pandemic changed the test quality of the pulmonary function test laboratory?

Introduction: Pulmonary function tests are used in the evaluation of the respiratory system. Maneuvers during spirometry can create aerosols and spread viruses such as SARS-CoV-2. Measures due to the pandemic can negatively affect both the number and the quality of the spirometry tests. There are no comparative studies on this subject. Materials and Methods: The tests conducted in the spirometry laboratory between November 2019 and November 2021 were evaluated. Result: Four hundred forty patients were included in the study. 50.5% of the patients were male and the mean age was 61.8 ± 16.5 years. The age, gender, height, and weight of the patients were similar. 75.2% (331) of the tests were evaluated as successful. The most common errors in tests were early termination (84.1%), uncooperative patients (29%), and poor effort (22.4%). The types of errors were not different between the two periods. The median number of tests performed for each patient was six. The total number of spirometry tests performed were 262 and 178 for 2019 and 2021 (p= 0.011), but test success remained unchanged over the years (p= 0.513). There was no significant difference between the three operators and the test success (p= 0.909), which was similar for both periods. However, the number of tests performed until the successful maneuver varied significantly (p= 0.009), and fewer maneuvers were required before the pandemic. Conclusions: According to this study, the measures taken during the pandemic did not affect the quality of spirometry, but they did lead to more tests being done up until the successful maneuver was performed.

Evaluation of Exudative Pleural Effusions: A Multicenter, Prospective, Observational Study.

PURPOSE: The aim of this study is to determine the diagnostic performances of pleural procedures in undiagnosed exudative pleural effusions and to evaluate factors suggestive of benign or malignant pleural effusions in tertiary care centers. METHODS: This was a multicenter prospective observational study conducted between January 1 and December 31, 2018. A total of 777 patients with undiagnosed exudative pleural effusion after the initial work-up were evaluated. The results of diagnostic procedures and the patients' diagnoses were prospectively recorded. Sensitivity, specificity, and accuracy estimates with 95% confidence intervals were used to examine the performance of pleural procedures to detect malignancy. RESULTS: The mean age ± SD of the 777 patients was 62.0 ± 16.0 years, and 68.3% of them were male. The most common cause was malignancy (38.3%). Lung cancer was the leading cause of malignant pleural effusions (20.2%). The diagnostic sensitivity and accuracy of cytology were 59.5% and 84.3%, respectively. The diagnostic sensitivity of image-guided pleural biopsy was 86.4%. The addition of image-guided pleural biopsy to cytology increased diagnostic sensitivity to more than 90%. Thoracoscopic biopsy provided the highest diagnostic sensitivity (94.3%). The highest diagnostic sensitivity of cytology was determined in metastatic pleural effusion from breast cancer (86.7%). CONCLUSION: The diagnostic performance increases considerably when cytology is combined with image-guided pleural biopsy in malignant pleural effusions. However, to avoid unnecessary interventions and complications, the development of criteria to distinguish patients with benign pleural effusions is as important as the identification of patients with malignant pleural effusions.

Recurrence of primary disease following lung transplantation.

Lung transplant has become definitive treatment for patients with several end-stage lung diseases. Since the first attempted lung transplantation in 1963, survival has significantly improved due to advancement in immunosuppression, organ procurement, ex vivo lung perfusion, surgical techniques, prevention of chronic lung allograft dysfunction and bridging to transplant using extracorporeal membrane oxygenation. Despite a steady increase in number of lung transplantations each year, there is still a huge gap between demand and supply of organs available, and work continues to select recipients with potential for best outcomes. According to review of the literature, there are some rare primary diseases that may recur following transplantation. As the number of lung transplants increase, we continue to identify disease processes at highest risk for recurrence, thus shaping our future approaches. While the aim of lung transplantation is improving survival and quality of life, choosing the best recipients is crucial due to a shortage of donated organs. Here we discuss the common disease processes that recur and highlight its impact on overall outcome following lung transplantation.

Frequency of Direct Oral Anticoagulants Usage in Acute Pulmonary Thromboembolism Treatment in Turkey (TUPEDO).

Background: Direct oral anticoagulants (DOACs) have been used in acute pulmonary thromboembolism as an alternative to warfarin due to drug interactions, narrow therapeutic range, and necessary close International Normalized Ratio (INR) monitoring. Phase 3 study results have reported that these drugs are at least as effective as warfarin and beneficial in terms of bleeding; however, studies that present up-to-date life data are necessary. Aims: To evaluate the frequency of using DOACs, which are prescribed with a limited number of indications in our country, and real-life data results. Study Design: Cross-sectional study. Methods: This cross-sectional survey collected the clinical data (history, current treatment, treatment duration, etc.) of patients with pulmonary thromboembolism and who applied to the physician for follow-up between October 15, 2019, and March 15, 2020. The researchers kept the patient records sequentially. Results: Data from 836 patients with acute pulmonary thromboembolism from 25 centers were collected, and DOAC was used in 320 (38.5%) of them. The most preferred DOAC was rivaroxaban (n = 294, 91.9%). DOAC was mostly preferred because it could not provide an effective INR level with warfarin (n=133, 41.6%). Bleeding was observed in 13 (4%) patients. Conclusion: The use of direct oral anticoagulants is becoming almost as widespread as conventional therapy. Real-life data results are important for their contribution to clinical practice.

Small cell lung cancer stem cells display mesenchymal properties and exploit immune checkpoint pathways in activated cytotoxic T lymphocytes.

Small cell lung cancer (SCLC) is an aggressive tumor type with early dissemination and distant metastasis capacity. Even though optimal chemotherapy responses are observed initially in many patients, therapy resistance is almost inevitable. Accordingly, SCLC has been regarded as an archetype for cancer stem cell (CSC) dynamics. To determine the immune-modulatory influence of CSC in SCLC, this study focused on the characterization of CD44+CD90+ CSC-like subpopulations in SCLC. These cells displayed mesenchymal properties, differentiated into different lineages and further contributed to CD8+ cytotoxic T lymphocytes (CTL) responses. The interaction between CD44+CD90+ CSC-like cells and T cells led to the upregulation of checkpoint molecules PD-1, CTLA-4, TIM-3, and LAG3. In the patient-derived lymph nodes, CD44+ SCLC metastases were also observed with T cells expressing PD-1, TIM-3, or LAG3. Proliferation and IFN-γ expression capacity of TIM-3 and LAG3 co-expressing CTLs are adversely affected over long-time co-culture with CD44+CD90+ CSC-like cells. Moreover, especially through IFN-γ secreted by the T cells, the CSC-like SCLC cells highly expressed PD-L1 and PD-L2. Upon a second encounter with immune-experienced, IFN-γ-stimulated CSC-like SCLC cells, both cytotoxic and proliferation capacities of T cells were hampered. In conclusion, our data provide evidence for the superior potential of the SCLC cells with stem-like and mesenchymal properties to gain immune regulatory capacities and cope with cytotoxic T cell responses. With their high metastatic and immune-modulatory assets, the CSC subpopulation in SCLC may serve as a preferential target for checkpoint blockade immunotherapy .

Post-COVID syndrome: pulmonary complications

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people worlwide and caused a pandemic that is still ongoing. The virus can cause a disease named as COVID-19, which is composed of multi systemic manifestations with a pulmonary system predominance. As the time passes, we are dealing more and more with a wide variety of effects and complications of the disease in survivors as far as with concerns about the clinical outcome and the timeline of symptoms in different patients. Since the lungs are the most involved organs and the post-COVID prolonged and persistent effects are mainly related to the pulmonary system, it is crucial to define and predict the outcome and to determine the individuals that can progress to fibrosis and loss of function of lungs. This review summarizes the current literature regarding the pulmonary complications in post-COVID syndrome and the management of these conditions.

New challenges for management of COVID-19 patients: Analysis of MDCT based "Automated pneumonia analysis program".

PURPOSE: The aim of this study is to define the role of an "Automated Multi Detector Computed Tomography (MDCT) Pneumonia Analysis Program'' as an early outcome predictor for COVID-19 pneumonia in hospitalized patients. MATERIALS AND METHODS: A total of 96 patients who had RT-PCR proven COVID-19 pneumonia diagnosed by non-contrast enhanced chest MDCT and hospitalized were enrolled in this retrospective study. An automated CT pneumonia analysis program was used for each patient to see the extent of disease. Patients were divided into two clinical subgroups upon their clinical status as good and bad clinical course. Total opacity scores (TOS), intensive care unit (ICU) entry, and mortality rates were measured for each clinical subgroups and also laboratory values were used to compare each subgroup. RESULTS: Left lower lobe was the mostly effected side with a percentage of 78.12 % and followed up by right lower lobe with 73.95 %. TOS, ICU entry, and mortality rates were higher in bad clinical course subgroup. TOS values were also higher in patients older than 60 years and in patients with comorbidities including, Hypertension (HT), Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF) and malignancy. CONCLUSION: Automated MDCT analysis programs for pneumonia are fast and an objective way to define the disease extent in COVID-19 pneumonia and it is highly correlated with the disease severity and clinical outcome thus providing physicians with valuable knowledge from the time of diagnosis.

ERS International Congress 2020: highlights from the Thoracic Surgery and Transplantation Assembly.

The Thoracic Surgery and Lung Transplantation Assembly of the European Respiratory Society is delighted to present the highlights from the 2020 Virtual International Congress. We have selected four sessions that discussed recent advances in a wide range of topics. From the use of robotic surgery in thoracic surgery and extracorporeal life support as a bridge to lung transplantation, to lung transplantation in the era of new drugs. The sessions are summarised by early career members in close collaboration with the assembly leadership. We aim to give the reader an update on the highlights of the conference in the fields of thoracic surgery and lung transplantation.

Covid-19: The Biggest Threat of the 21st Century: In Respectful Memory of the Warriors All Over the World.

Since the first case was diagnosed in China, the new coronavirus infection (COVID-19) has become the number one issue in the world and it seems to remain trend-topic for a long time. Until 17 April, it affected 210 countries, infected over 2 million people and caused approximately 150000 deaths. Although the course of the disease ranges from asymptomatic state to severe ARDS; the majority of patients reveal only mild symptoms. Though adults are the most commonly affected group; it can also be seen in newborns and elderly patients. Unfortunately, elderly patients are the most vulnerable group with higher mortality. Elderly patients, smokers and patients with comorbid conditions are most affected by the disease. In certain diagnostical tool is the real-time reverse transcription-polymerase chain reaction (real-time RT-PCR) test. However, it can be resulted in false-negative results and in this case the computed thorax tomography (CT) is one of the most important tools with high sensitivity. Besides the supportive treatment, most commonly used agents are immunomodulatory drugs such as plaquenil and azitromycin, and anti-virals including oseltamivir, ritonavir-lopinavir, favipiravir. Until a vaccine or a specific therapy invented, the most important intervention to control the disease is to fight against transmission. This is a real war and the doctors are the soldiers.

COVID-19 Treatment at a Glance.

As coronavirus disease 2019 (COVID-19) spreads across the world, the ongoing clinical trials are leading to a big race worldwide to develop a treatment that will help control the pandemic. Unfortunately, COVID-19 does not have any known effective treatment with reliable study results yet. In this pandemic, there is not a lot of time to develop a new specific agent because of the rapid spread of the disease. The process of developing a vaccine is long and requires hard work. Although the pathophysiology of the disease is not fully understood, some of the proposed treatment alternatives are based on old evidence and some have been used with the idea that they might work owing to their mechanism of action. The efficacy, reliability, and safety of the currently available treatment alternatives are therefore a matter of debate. Currently, the main therapies used in the treatment of COVID-19 are antiviral drugs and chloroquine/hydroxychloroquine. Other proposed options include tocilizumab, convalescent plasma, and steroids, but the mainstay of the treatment in intensive care units remains supportive therapies.

Nowadays COVID underestimates the other suspects.

The whole world has been facing the pandemic of SARS-CoV-2 infection and every day we still find out new knowledge regarding the disease. COVID-19 which is the name given to the clinical syndrome related to this infection has been shown to own a wide diversity of clinical presentations which challenges the healthcare workers and makes difficult the diagnosis and management of patients. Pulmonary embolism is also an entity that accompanies this type of infection and sometimes it is difficult to differentiate between the two. Here we present a patient who was admitted inward with typical lesions on chest tomography for COVID-19, but that turned out to be a submassive pulmonary embolism case without any infection. This case is remarkable because it shows that patients suspected for COVID-19 should be carefully examined and that pulmonary embolism can per se mimick the parenchymal lesions caused by viral infections.

Unclear Issues Regarding COVID-19.

Scientists from all over the world have been intensively working to discover different aspects of Coronavirus disease 2019 (COVID-19) since the first cluster of cases was reported in China. Herein, we aimed to investigate unclear issues related to transmission and pathogenesis of disease as well as accuracy of diagnostic tests and treatment modalities. A literature search on PubMed, Ovid, and EMBASE databases was conducted, and articles pertinent to identified search terms were extracted. A snow-ball search strategy was followed in order to retrieve additional relevant articles. It was reported that viral spread may occur during the asymptomatic phase of infection, and viral load was suggested to be a useful marker to assess disease severity. In contrast to immune response against viral infections, cytotoxic T lymphocytes decline in SARS-CoV-2 infection, which can be partially explained by direct invasion of T lymphocytes or apoptosis activated by SARS-CoV-2. Dysregulation of the urokinase pathway, cleavage of the SARS-CoV-2 Spike protein by FXa and FIIa, and consumption coagulopathy were the proposed mechanisms of the coagulation dysfunction in COVID-19. False-negative rates of reverse transcriptase polymerase chain reaction varied between 3% and 41% across studies. The probability of the positive test was proposed to decrease with the number of days past from symptom onset. Safety issues related to infection spread limit the use of high flow nasal oxygen (HFNO) and continuous positive airway pressure (CPAP) in hypoxic patients. Further studies are required to elucidate the challenging issues, thus enhancing the management of COVID-19 patients.

What We Learned about COVID-19 So Far? Notes from Underground.

The novel coronavirus pandemic poses a major global threat to public health. Our knowledge concerning every aspect of COVID-19 is evolving rapidly, given the increasing data from all over the world. In this narrative review, the Turkish Thoracic Society Early Career Taskforce members aimed to provide a summary on recent literature regarding epidemiology, clinical findings, diagnosis, treatment, prevention, and control of COVID-19. Studies revealed that the genetic sequence of the novel coronavirus showed significant identity to SARS-CoV and MERS-CoV. Angiotensin-converting enzyme 2 receptor is an important target of the SARS-CoV-2 while entering an organism. Smokers were more likely to develop the disease and have a higher risk for ICU admission. The mean incubation period was 6.4 days, whereas asymptomatic transmission was reported up to 25 days after infection. Fever and cough were the most common symptoms, and cardiovascular diseases and hypertension were reported to be the most common comorbidities among patients. Clinical manifestations range from asymptomatic and mild disease to severe acute respiratory distress syndrome. Several patients showed typical symptoms and radiological changes with negative RT-PCR but positive IgG and IgM antibodies. Although radiological findings may vary, bilateral, peripherally distributed, ground-glass opacities were typical of COVID-19. Poor prognosis was associated with older age, higher Sequential Organ Failure Assessment score, and high D-dimer level. Chloroquine was found to be effective in reducing viral replication in vitro. Likewise, protease inhibitors, including lopinavir/ritonavir, favipiravir, and nucleoside analogue remdesivir were proposed to be the potential drug candidates in COVID-19 management. Despite these efforts, we still have much to learn regarding the transmission, treatment, and prevention of COVID-19.