The association of antiviral drugs with COVID-19 morbidity: The retrospective analysis of a nationwide COVID-19 cohort.

Background and objectives: Although several repurposed antiviral drugs have been used for the treatment of COVID-19, only a few such as remdesivir and molnupiravir have shown promising effects. The objectives of our study were to investigate the association of repurposed antiviral drugs with COVID-19 morbidity. Methods: Patients admitted to 26 different hospitals located in 16 different provinces between March 11-July 18, 2020, were enrolled. Case definition was based on WHO criteria. Patients were managed according to the guidelines by Scientific Board of Ministry of Health of Turkey. Primary outcomes were length of hospitalization, intensive care unit (ICU) requirement, and intubation. Results: We retrospectively evaluated 1,472 COVID-19 adult patients; 57.1% were men (mean age = 51.9 ± 17.7years). A total of 210 (14.3%) had severe pneumonia, 115 (7.8%) were admitted to ICUs, and 69 (4.7%) were intubated during hospitalization. The median (interquartile range) of duration of hospitalization, including ICU admission, was 7 (5-12) days. Favipiravir (n = 328), lopinavir/ritonavir (n = 55), and oseltamivir (n = 761) were administered as antiviral agents, and hydroxychloroquine (HCQ, n = 1,382) and azithromycin (n = 738) were used for their immunomodulatory activity. Lopinavir/ritonavir (ß [95% CI]: 4.71 [2.31-7.11]; p = 0.001), favipiravir (ß [95% CI]: 3.55 [2.56-4.55]; p = 0.001) and HCQ (ß [95% CI]: 0.84 [0.02-1.67]; p = 0.046) were associated with increased risk of lengthy hospital stays. Furthermore, favipiravir was associated with increased risks of ICU admission (OR [95% CI]: 3.02 [1.70-5.35]; p = 0.001) and invasive mechanical ventilation requirement (OR [95% CI]: 2.94 [1.28-6.75]; p = 0.011). Conclusion: Our findings demonstrated that antiviral drugs including lopinavir, ritonavir, and favipiravir were associated with negative clinical outcomes such as increased risks for lengthy hospital stay, ICU admission, and invasive mechanical ventilation requirement. Therefore, repurposing such agents without proven clinical evidence might not be the best approach for COVID-19 treatment.

Comparison of full-face and oronasal mask effectiveness in hypercapnic respiratory failure patients with non-invasive mechanical ventilation.

Introduction: Non-invasive mechanical ventilation (NIMV) is a successful treatment modality in hypercapnic respiratory failure. Patient compliance and mask selection are the most important factors in the success of NIMV. In our prospective randomized study, we aimed to investigate the efficacy of full-face and oronasal masks in the treatment of patients with hypercapnic respiratory failure who underwent NIMV and to investigate the mask compliance of the patients. Materials and Methods: In this prospective randomized study, 60 patients with hypercapnic respiratory failure were divided into two groups; the full face mask group (n= 30) and the oronasal mask group (n= 30). Arterial blood gas values and respiratory rates were measured before the treatment and at the 1st, 6th, 24th, and 72nd hours of the treatment. The compliance of the patients with the treatment was evaluated with the patient compliance scale (PCS) at the 1st, 6th, and 24th hours of the treatment. Result: Eight patients from the full-face mask group were excluded because of mask-face mismatch and claustrophobia, and two patients from the oronasal mask group due to persistent hypercapnia. In the full face mask group, improvement in pH was observed at the 1st and 24th hours of treatment (p= 0.042, p= 0.033), and PCO2 decreased at the 72nd hour of treatment (p= 0.024). There was no difference in patient compliance and respiratory rate between groups. The complaints of burning sensation and pressure in the eyes were higher in the full face mask group (p= 0.025), and pressure ulcers were more common in the oronasal mask group (p= 0.025). Conclusions: The reduction in PCO2 and improvement in pH were greater with a full face mask. Pressure sores were less common with a full face mask. In our study, no difference was found in terms of patient compliance between groups. It should be noted that choosing a full face mask in patients with high compliance will increase the success in the treatment of hypercapnic respiratory failure.

The predictors of COVID-19 mortality in a nationwide cohort of Turkish patients.

The COVID-19-related death rate varies between countries and is affected by various risk factors. This multicenter registry study was designed to evaluate the mortality rate and the related risk factors in Turkey. We retrospectively evaluated 1500 adults with COVID-19 from 26 centers who were hospitalized between March 11 and July 31, 2020. In the study group, 1041 and 459 cases were diagnosed as definite and highly probable cases, respectively. There were 993 PCR-positive cases (66.2%). Among all cases, 1144 (76.3%) were diagnosed with non-severe pneumonia, whereas 212 (14.1%) had severe pneumonia. Death occurred in 67 patients, corresponding to a mortality rate of 4.5% (95% CI:3.5-5.6). The univariate analysis demonstrated that various factors, including male sex, age ≥65 years and the presence of dyspnea or confusion, malignity, chronic obstructive lung disease, interstitial lung disease, immunosuppressive conditions, severe pneumonia, multiorgan dysfunction, and sepsis, were positively associated with mortality. Favipiravir, hydroxychloroquine and azithromycin were not associated with survival. Following multivariate analysis, male sex, severe pneumonia, multiorgan dysfunction, malignancy, sepsis and interstitial lung diseases were found to be independent risk factors for mortality. Among the biomarkers, procalcitonin levels on the 3rd-5th days of admission showed the strongest associations with mortality (OR: 6.18; 1.6-23.93). This study demonstrated that the mortality rate in hospitalized patients in the early phase of the COVID-19 pandemic was a serious threat and that those patients with male sex, severe pneumonia, multiorgan dysfunction, malignancy, sepsis and interstitial lung diseases were at increased risk of mortality; therefore, such patients should be closely monitored.

Levels and Predictors of Anxiety, Depression, and Burnout Syndrome in Physicians During the COVID-19 Pandemic.

This study intended to observe mental symptoms among physicians in Turkey during the COVID-19 pandemic and to investigate the factors leading to such symptoms. The study participants were contacted via their smartphones between April 23 and 27, 2020, and invited to fill out an online questionnaire which included questions from the Hospital Anxiety and Depression Scale (HADS) and the Maslach Burnout Inventory (MBI). The mean age of the 406 physicians who participated in the study was 42.9 ± 10.1 years, and 53.4% were men (n: 217). During the pandemic, 66.7% had decreased working hours. Lack of COVID-related training, difficulty obtaining personal protective equipment (PPE), working in a COVID unit, and current psychiatric disease were found to be among the predictors of emotional burnout. Female gender, lack of COVID training, difficulty obtaining PPE, working in a COVID unit, and current psychiatric disease predicted desensitization. Facilitating continuous and comprehensive support mechanisms aimed at protecting physicians' mental health is of great importance during epidemics.

Tuberculosis Arthritis in the Wrist While Using Rituximab for Rheumatoid Arthritis Treatment.

INTRODUCTION: Data from clinical trials indicate that there are no increased risk of tuberculosis (TB) infections in rheumatoid arthritis (RA) patients while using rituximab (RTX). Herein, we report a RA patient who developed TB arthritis while using RTX. CASE REPORT: A 49-year-old patient was treated with methotrexate and prednisolone along with RTX for two years. Later, she presented with increasing pain, swelling, redness and cutaneous fistulization in her left wrist for two months. The lesion on the wrist was debritted. Histopathologic evaluation revealed the presence of acid-fast bacilli. Polymerase chain reaction test and culture confirmed mycobacterium tuberculosis. RTX, methotrexate and prednisolone were withdrawn. The patient was treated with 12-month course of antituberculous treatment and responded well. The patient, who did not have pain or swelling in her other joints, was not given any treatment for RA after antituberculous treatment. CONCLUSION: Clinicians should keep in mind that TB infections may be encountered while using RTX. Latent TB screening may be appropriate in patients using concomitant corticosteroid and living in TB endemic areas.

The objective evaluation of obstructive pulmonary diseases with spirometry.

Airway obstruction is variable in asthma, while it is progressive and persistent in chronic bronchitis and emphysema. However, some of the patients presenting with symptoms of chronic airway diseases have clinical features of both asthma and COPD. The group with "Asthma-COPD Overlap Syndrome" (ACOS) phenotype was characterized by definitely irreversible airway obstruction accompanied by symptoms and signs of reversibility. In this study, we aimed to classify obstructive airway diseases by clinical, radiological, and pulmonary function tests. Patients at Samsun Medical Park Hospital Chest Diseases outpatient clinic were evaluated between January 2013 and April 2016, and a total of 235 patients were included in this study. Mean age of the patients was 55.3±14.5 (15-88) years, and the male/female ratio was 45/190. The baseline pulmonary function test results of the patients were as follows: mean forced vital capacity (FVC) values 2,825±1,108 (710-6,870) mL and 74.3±22.4 (24-155)%, forced expiratory volume in 1 second (FEV1) values 1,789±774 (480-4,810) mL and 58.1±20.0 (20-130)%, FEV1/FVC values 62.5±6.8 (39-70)%. Reversibility criteria following bronchodilator treatment were present in 107 (45.5%) patients. We specified five subgroups for patients according to their clinical, radiological, and pulmonary test findings, namely Group 1 (asthma), Group 2 (ACOS), Group 3 (chronic bronchitis), and Group 4 (emphysema). Additionally, a group of patients who had clinical and spirometric features of both asthma and chronic bronchitis in association with underlying emphysema (emphysema with chronic bronchitis and emphysema with asthma) was defined as the undifferentiated obstruction (UNDO) group. Number and percentage distribution of patients by groups were 58 (24.7%) in the asthma group, 70 (29.8%) in the ACOS group, 61 (26%) in the chronic bronchitis group, 32 (13.6%) in the emphysema group, and 14 (6%) in the UNDO group. In conclusion, in our study, the types of obstructive airway diseases could be classified based on clinical, radiological, and pulmonary function test findings into five groups, including asthma, ACOS, chronic bronchitis, emphysema, and both asthma and chronic bronchitis in association with underlying emphysema (emphysema with chronic bronchitis and emphysema with asthma) or the so-called undifferentiated obstruction. We suggest that these patient groups can be determined more accurately by studies that evaluate the association between spirometric FEV1, FEV1/FVC values, and reversibility ratios.

Diagnostic efficacy of computed tomography-guided transthoracic needle aspiration and biopsy in patients with pulmonary disease.

BACKGROUND: Computed tomography-guided transthoracic needle aspiration (TTNA) and biopsy (TTNB) is a well established, safe, and rapid method of reaching a definitive diagnosis for most thoracic lesions. The present study aimed to determine the roles of TTNA and TTNB in the diagnosis of pulmonary diseases and to compare the results using these two techniques. METHODS: TTNB and TTNA were performed in 105 patients admitted to our clinic due to peripheral pulmonary lesions between May 2005 and November 2007. Needle biopsies were performed using 18-gauge Tru-Cut® biopsy needles and aspirations was performed using 18-20-22-gauge Chiba needles. RESULTS: Malignant lesions diagnosed by TTNB were non-small cell lung carcinoma (51 patients, 73%), small cell lung carcinoma (nine patients, 13%), malignant tissue (three patients, 5%), lymphoma (two patients, 3%), thymoma (two patients, 3%), plasmacytoma (one patient, 1%), rhabdomyosarcoma (one patient, 1%), and metastasis (one patient, 1%). The malignant lesions diagnosed by TTNA were non-small cell lung carcinoma in eleven patients (92%) and malignant tissue in one patient (8%). Three (100%) of the benign lesions diagnosed by TTNB were granulomas and two (100%) benign lesions diagnosed by TTNA were infarctions. When the diagnostic value of TTNB and TTNA was compared, TTNB was significantly superior. Malignant lesions were identified in 70 (84%) and benign lesions were identified in three (4%) of the 83 patients in the TTNB group. Ten (12%) patients in the TTNB group could not be diagnosed. Malignant lesions were found in 12 (55%) and benign lesions were found in two (9%) of the 22 patients in the TTNA group. Negative results were obtained in eight (36%) patients. The diagnostic sensitivity, specificity, and accuracy of TTNB was calculated to be 92%, 100%, and 93%, respectively (Table 5). The diagnostic sensitivity, specificity, and accuracy of TTNA was 78%, 100%, and 82%, respectively. TTNB had a sensitivity of 92% (70/76) in malignant cases and 100% (3/3) in benign cases, while the sensitivity of TTNA in malignant and benign cases was 75% (3/4) and 67% (2/3), respectively. CONCLUSION: TTNB is a safe and easy procedure which provides a highly accurate diagnosis of benign and malignant lung lesions without causing a significant increase in complication rates.

A new syndrome: right-sided arcus aorta syndrome.

Right-sided arcus aorta (RSAA) is a rare congenital anomaly that may cause chronic cough and dyspnoea. We aimed to define RSAA as a new syndrome characterised by RSAA, dyspnoea and cough during exercise. RSAA syndrome should be included in the differential diagnosis of asthma.

The effects of long-acting ß2-agonists plus inhaled corticosteroids for early reversibility in patients with airway obstruction.

BACKGROUND: Salbutamol, as a short-acting ß2-agonist, was popularly used in the past for detection of reversibility in patients with airway obstruction when it was the only drug available in the treatment of airway obstruction. Today, the combination of long-acting ß2-agonists (LABA) and inhaled glucocorticoids are the first choice of therapy, with or without the presence of reversibility, in patients with airway obstruction. We aimed to compare the efficacy of salbutamol and long acting ß2-agonists plus inhaled glucocorticoids for early reversibility test in patients with airway obstruction. METHODS: Symptomatic patients (cough, dyspnea, and/or wheezing) with airway obstruction according to pulmonary function testing (FEV1/FVC value less than 70% of expected) who had never used bronchodilators before or had not received short- or long-acting inhaled bronchodilator therapy within the most recent 12 hours were evaluated. Reversibility measurements were made by administering the combination of long-acting ß2-agonists (LABA) and inhaled glucocorticoids after 15 minutes. RESULTS: A total of 90 patients were evaluated. The mean age of patients was 57.3±17.7 (range, 8-88) years and the male-to-female ratio was 69/21. The baseline pulmonary function test results were mean FVC; 2,747±1,181 mL and 74.7%±21.4%, mean FEV1; 1,716±825 mL and 57.5%±19.0%, mean FEV1/FVC; 61.4%±7.4%. The bronchodilator drugs given before reversibility testing were as salmeterol/fluticasone (FTC/SAL), formoterol/budesonide (BUD/FOR), beclomethasone dipropionate/formoterol (BDP/FOR) and salbutamol (SLB) in 24, 22, 24 and 20 patients, respectively. The reversibility was positive in 33 (36.7%) patients. The absolute change and percentage of change in mean FEV1 were 206±252 mL, 13.2%±16.6% for FTC/SAL group, 273±201 mL, 14%±8% for BUD/FOR group, 240±151 mL, 18.7%±15.9% for BUD/FOR groupand 171±116 mL, 13.3%±11.8% for SLB group. There was no statistically significant for reversibilty results between LABAs/inhaledsteroids and SLB group. And the patients with positivere versibility test were significantly higher in both of BUD/FOR and BDP/FOR groups than SLB group. CONCLUSIONS: We think that performance of an early reversibility test using the combination of a LABA and an inhaled corticosteroid for treatment would enhance both the education of the patient in using the device and the reliability of the drug. And, we suggest that: "you should make the reversibility test with Long-Acting ß2-Agonists plus Inhaled Corticosteroids which used in treatment of obstructive lung diseases".

An intracerebral mass: tuberculosis or sarcoidosis?

Sarcoidosis is an idiopathic, chronic granulomatous disease and it can affect almost any organ. In autopsy series, it has been reported that the central nervous system involvement has occurred in 5-16% of the patients with sarcoidosis, while the neurological symptoms have occurred only in 3-9% of them. A 40-year-old female patient was admitted to the hospital with complaints of aphasia, balance disorder and drowsiness. An intracerebral mass was detected on cranial CT scans and neurosarcoidosis was diagnosed with clinical, radiological and histopathological findings.

Massive hemoptysis due to welding fumes.

Many pulmonary problems such as lung cancer, occupational asthma, and pneumoconiosis have been described due to welding in the literature until now. This is the first case report of alveolar hemorrhage due to welding fumes presented with massive hemoptysis. We report a rare case of massive hemopthisis associated with welder's lung, with a discussion based on a review of the literature. ESTABLISHED FACTS: Many pulmonary diseases such as lung cancer, occupational asthma, and pneumoconiosis have been attributed welding fumes in the literature. Alveolar hemorrhage due to welding fumes has never defined before. NOVEL INSIGHTS: We herein report a case of alveolar hemorrhage presented with massive hemoptysis due to welding fumes. Clinicians should be aware of such rare but serious clinical picture which can occur in welding workers. Palliative measures and bronchoscopic Ankaferd Blood Stopper(®) application may help to stop bleeding.