Pneumonia severity indices predict prognosis in coronavirus disease-2019.

BACKGROUND: Early recognition of the severe illness is critical in coronavirus disease-19 (COVID-19) to provide best care and optimize the use of limited resources. OBJECTIVES: We aimed to determine the predictive properties of common community-acquired pneumonia (CAP) severity scores and COVID-19 specific indices. METHODS: In this retrospective cohort, COVID-19 patients hospitalized in a teaching hospital between 18 March-20 May 2020 were included. Demographic, clinical, and laboratory characteristics related to severity and mortality were measured and CURB-65, PSI, A-DROP, CALL, and COVID-GRAM scores were calculated as defined previously in the literature. Progression to severe disease and in-hospital/overall mortality during the follow-up of the patients were determined from electronic records. Kaplan-Meier, log-rank test, and Cox proportional hazard regression model was used. The discrimination capability of pneumonia severity indices was evaluated by receiver-operating-characteristic (ROC) analysis. RESULTS: Two hundred ninety-eight patients were included in the study. Sixty-two patients (20.8%) presented with severe COVID-19 while thirty-one (10.4%) developed severe COVID-19 at any time from the admission. In-hospital mortality was 39 (13.1%) while the overall mortality was 44 (14.8%). The mortality in low-risk groups that were identified to manage outside the hospital was 0 in CALL Class A, 1.67% in PSI low risk, and 2.68% in CURB-65 low-risk. However, the AUCs for the mortality prediction in COVID-19 were 0.875, 0.873, 0.859, 0.855, and 0.828 for A-DROP, PSI, CURB-65, COVID-GRAM, and CALL scores respectively. The AUCs for the prediction of progression to severe disease was 0.739, 0.711, 0,697, 0.673, and 0.668 for CURB-65, CALL, PSI, COVID-GRAM, A-DROP respectively. The hazard ratios (HR) for the tested pneumonia severity indices demonstrated that A-DROP and CURB-65 scores had the strongest association with mortality, and PSI, and COVID-GRAM scores predicted mortality independent from age and comorbidity. CONCLUSION: Community-acquired pneumonia (CAP) scores can predict in COVID-19. The indices proposed specifically to COVID-19 work less than nonspecific scoring systems surprisingly. The CALL score may be used to decide outpatient management in COVID-19.

Accuracy and feasibility of dynamic contrast-enhanced 3D MR imaging in the assessment of lung perfusion: comparison with Tc-99 MAA perfusion scintigraphy.

AIM: The aim of this study was to correlate findings of perfusion magnetic resonance imaging (MRI) and perfusion scintigraphy in cases where there was a suspicion of abnormal pulmonary vasculature, and to evaluate the usefulness of MRI in the detection of perfusion deficits of the lung. METHODS: In all, 17 patients with suspected abnormality of the pulmonary vasculature underwent dynamic contrast-enhanced MRI. T1-weighted 3D fast-field echo pulse sequences were obtained (TR/TE 3.3/1.58 ms; flip angle 30 degrees; slice thickness 12 to 15 mm). The dynamic study was acquired in the coronal plane following administration of 0.1 mmol/kg gadopentetate dimeglumine. A total of 8 to 10 sections repeated 20 to 25 times at intervals of 1s were performed. Perfusion lung scintigraphy was carried out a maximum of 48 h before the MR examination in all cases. Two radiologists, who were blinded to the clinical data and results of other imaging methods, reviewed all coronal sections. MR perfusion images were independently assessed in terms of segmental or lobar perfusion defects in the 85 lobes of the 17 individuals, and the findings were compared with the results of scintigraphy. RESULTS: Of the 17 patients, 8 were found to have pulmonary emboli, 2 chronic obstructive pulmonary disease with emphysema, 2 bullous emphysema, 2 Takayasu arteritis and 1 had a hypoplastic pulmonary artery. Pulmonary perfusion was completely normal in 2 cases. In 35 lobes, perfusion defects were detected using both methods, in 4 with MR alone and in 9 only with scintigraphy. There was good agreement between MRI and scintigraphy findings (kappa=0.695). CONCLUSION: Pulmonary perfusion MRI is a new alternative to scintigraphy in the evaluation of pulmonary perfusion for various lung disorders. In addition, this technique allows measurement and quantification of pulmonary perfusion abnormalities.

Risk of tuberculosis among healthcare workers: can tuberculosis be considered as an occupational disease?

This study aimed to determine the incidence of tuberculosis among hospital employees in four major urban institutions, which employ nearly 90% of all hospital workers caring for adult patients in a city of 2.5 million inhabitants. It also had the objective of finding out whether this incidence changes according to the in-hospital setting, i.e. the departments, and thus, whether tuberculosis can be considered to pose an occupational risk. The study population consisted of all healthcare workers of the four hospitals between 1986 and 1998. From these, those who developed tuberculosis within this period were determined and were considered as the case group. All the remaining employees constituted the control group. Fifty-nine healthcare workers were found to have developed the disease. The annual incidence was found to range between 0.016 and 0.139%. Tuberculosis was seen 3 times more frequently among the hospital employees than the general population. The workers in departments of chest diseases were found to have a higher risk than those of other departments (OR: 6.37, CI: 3.69-11.00). Similarly, the nurses were also at a higher risk than the doctors (OR: 2.63, CI: 1.12-6.36). These findings suggest that tuberculosis can be considered as an occupational disease.

Clearance of Tc-99m DTPA aerosol in mismatched and matched pulmonary perfusion defects.

PURPOSE: To evaluate clearance changes of Tc-99m DTPA aerosol in mismatched and matched pulmonary perfusion defects. MATERIALS AND METHODS: Twenty-one patients (14 women, 7 men; mean age, 51 +/- 14 years) with possible pulmonary embolism were included in the study. On the day after perfusion (Q) scintigraphy with 5 mCi Tc-99m MAA, radioaerosol inhalation scintigraphy was performed using 45 mCi Tc-99m DTPA. Immediately and 45 minutes after the inhalation, early and delayed inhalation images (EI and DI, respectively) were obtained. Group 1 included 11 patients with mismatched defects who had a high probability of pulmonary embolism according to the Q/EI scan results. Group 2 included 10 patients with matched defects who had a low probability of PE. Contralateral normal lungs of 7 patients in group 2 served as controls (group 3). In groups 1 and 2, regions of interest were drawn over the mismatched and matched perfusion defects where they were best visualized, and this region of interest was mirrored to the same region on EI and DI images. For the control group, this was done in the contralateral normal lung. Mean counts in each region of interest were used for quantitative analysis, and the percentage clearance ratio was calculated using the following formula: early counts - late counts/early counts x 100. RESULTS: The average percentage clearances for the three groups were as follows: group 1, 37% +/- 10%; group 2, 21% +/- 4%; group 3, 24% +/- 7%. Differences between groups 1 and 3 were significant, as were those between groups 1 and 2 (P < 0.05). Patients with mismatched perfusion defects had increased DTPA clearance compared with the control group and those with matched defects. CONCLUSIONS: Vascular occlusion may lead to impairment of the alveolar-capillary barrier and consequently an increase in the clearance of Tc-99m DTPA aerosol in embolized regions. Immediately after inhalation, Tc-99m DTPA imaging should be started in the projection where perfusion defects are best seen to avoid potential misinterpretation of pulmonary embolism.

Water-pipe smoking and pulmonary functions.

Water-pipe smoking is a type of smoking habit, widely encountered in Turkey and Arabic and Middle East countries. However there is limited data about the effects of water-pipe smoking. The aim of this study is to investigate this habit with regard to the duration and amount of smoking and to analyse its characteristics and effects on pulmonary function by the correlation of the results with those of cigarette smokers and non-smokers. All cafés in Izmir city were visited for this purpose. A total of 397 males were studied in four groups: water-pipe smokers, water-pipe smokers who used to smoke cigarettes, active cigarette smokers and non-smokers. After recording a detailed history of smoking, pulmonary function tests on each person were performed. There were statistically significant differences between cigarette smokers and non-smokers within most of the parameters. The results of recent study have shown that the detrimental effects on pulmonary function of water-pipe smoking are not as great as cigarette smoking (FEV1, FEV1/FVC parameters were higher in water-pipe smokers), especially on the parameters for small airways (FEF50, MMEF parameters were higher in water-pipe smokers) (P < 0.05). It is difficult to explain the reasons exactly without estimating possible mechanisms in detail, but the most likely mechanisms arise from the smoking technique itself which involves a water filter and a long spout through which the smoke passes before reaching the lungs.

Effects of haemodialysis on pulmonary clearance of Tc-99m diethylene triamine pentaacetate (DTPA).

OBJECTIVES: Hypoxaemia occurring during haemodialysis has long been known. Several mechanisms in the pathogenesis have been proposed. The present study was conducted to test whether changes in pulmonary alveolar permeability were among the operating mechanisms. MATERIALS AND METHODS: Twenty haemodialysis patients (12 male, 8 female) were included in the study. The mean age was 49 years (age range: 18-85 years). Patients with known pulmonary disease, current smokers and those gaining more than 1 kg weight during the interdialytic period were excluded. Complete blood count, arterial blood gas analysis, pulmonary function tests and Tc-99m diethylene triamine pentaacetate (DTPA) inhalation scintiscan were carried out before and after haemodialysis. A bronchial provocation test was carried out after each session. A postero-anterior chest radiogram was taken for each patient. RESULTS: When the results before and after haemodialysis were compared, it was observed that the pH and serum bicarbonate levels, haemoglobin and haematocrit values were significantly higher after haemodialysis. However, the platelet count was found to be decreased significantly. Bronchial hyperreactivity, tested by metacholine, Was positive in 5 of 19 patients (26%). No correlation between bronchial hyperreactivity and other factors could be identified. No significant difference was observed in pulmonary Tc-99m DTPA clearance after haemodialysis. All chest radiograms were interpreted to be within normal limits. CONCLUSIONS: Since we observed no hypoxaemia following haemodialysis, we cannot comment as to whether the changes in pulmonary clearance play a role in the pathogenesis of haemodialysis-associated hypoxaemia. In order to reach reliable conclusions, additional studies are needed.

Technetium-99m-tetrofosmin scintigraphy in pulmonary tuberculosis.

UNLABELLED: Technetium-99m-tetrofosmin, an agent that is widely used in myocardial imaging, has been reported to accumulate in several types of malignancies, including lung tumors. Yet, there is limited knowledge about its role in imaging infection or inflammatory lesions. The aim of this study was to investigate the role of 99mTc-tetrofosmin scintigraphy in pulmonary tuberculosis in cases with active and inactive tuberculosis in comparison with radiological and microbiological findings. METHODS: Twenty-seven patients with active pulmonary tuberculosis (APTB) and 6 patients with inactive pulmonary tuberculosis (IPTB), proven by sputum smears and cultures, were included in this study. Mean age of the group was 42.6+/-13 yr. Nine months after therapy, 99mTc-tetrofosmin scintigraphy was repeated in 6 patients with APTB to evaluate response to therapy. Ten-minute anterior and posterior chest images were acquired 20 and 60 min after the injection of 370 MBq (10 mCi) 99mTc-tetrofosmin. The images were evaluated both visually and semiquantitatively by two blinded nuclear medicine physicians. For semiquantitative evaluation, regions of interest (ROIs) were drawn over the lesion (L) and nonlesion areas (NL). The mean count values of ROIs were obtained and L/NL ratios were calculated. RESULTS: According to the visual evaluations, 99mTc-tetrofosmin uptake was Grade (+) in 4 (15%) and Grade (++) in 23 (85%) patients with APTB. Technetium-99m-tetrofosmin uptake was negative in 5 patients with IPTB. Grade (+) 99mTc-tetrofosmin uptake was observed in only one inactive case. After therapy, there was no 99mTc-tetrofosmin uptake in 3 patients, which correlated well with chest radiography and clinical findings. In the other 2 patients, 99mTc-tetrofosmin uptake was slightly decreased when compared with a previous scan that correlated with radiological and clinical findings. In 1 patient with bilateral lung disease, 99mTc-tetrofosmin uptake decreased on the right lung lesions, whereas the left lung lesions persisted with no change. The mean early and delayed L/NL ratios of APTB were 1.53+/-0.22 and 1.45+/-0.21, respectively. Although 99mTc-tetrofosmin uptake in APTB lesions was more visually marked in early images than that in delayed images, there was no statistically significant difference between these two sets of images. CONCLUSION: Technetium-99m-tetrofosmin scintigraphy showed increased uptake in APTB lesions related to disease activity. After treatment, 99mTc-tetrofosmin uptake disappeared or decreased, correlating well with radiological and clinical findings. Technetium-99m-tetrofosmin scintigraphy may have a complementary role in the assessment of APTB as well as in follow-up treatment.

Behçet's disease with pulmonary involvement, superior vena cava syndrome, chyloptysis and chylous ascites.

Behçet's disease is a chronic multisystem vasculitis of unknown aetiology. This case report describes a patient who applied to the hospital because of dyspnoea, ascites, oedema of lower extremities and recurrent episodes of haemoptysis. For the last 12 yr, he had superior vena cava syndrome (SVCS) and cardiac and pulmonary involvement of Behçet's disease, and biochemical examination of ascite fluid yielded a chylous effusion containing triglyceride 421 mg dl-1 and cholesterol 49 mg dl-1. Chyloptysis was also detected by Sudan III stain. The patient died from cardiac tamponade in spite of cardiac fenestration. To the authors' knowledge, this is the first reported case of Behçet's disease with chylous ascites and chyloptysis in the English literature.

High resolution computed tomographic findings in pulmonary tuberculosis.

BACKGROUND: Although chest radiographs usually provide adequate information for the diagnosis of active pulmonary tuberculosis, minimal exudative tuberculosis can be overlooked on standard chest radiographs. The aim of the present study was to assess the findings of active pulmonary tuberculosis on high resolution computed tomographic (HRCT) scans, and to evaluate their possible use in determining disease activity. METHODS: Thirty two patients with newly diagnosed active pulmonary tuberculosis and 34 patients with inactive pulmonary tuberculosis were examined. The diagnosis of active pulmonary tuberculosis was based on positive acid fast bacilli in sputum and bronchial washing smears or cultures and/or changes on serial radiographs obtained during treatment. RESULTS: With HRCT scanning centrilobular lesions (n = 29), "tree-in-bud" appearance (n = 23), and macronodules 5-8 mm in diameter (n = 22) were most commonly seen in cases of active pulmonary tuberculosis. HRCT scans showed fibrotic lesions (n = 34), distortion of bronchovascular structures (n = 32), emphysema (n = 28), and bronchiectasis (n = 24) in patients with inactive tuberculosis. CONCLUSIONS: Centrilobular densities in and around the small airways and "tree-in-bud" appearances were the most characteristic CT features of disease activity. HRCT scanning clearly differentiated old fibrotic lesions from new active lesions and demonstrated early bronchogenic spread. These findings may be of value in decisions on treatment.

Pulmonary alveolar microlithiasis: review of Turkish reports.

Pulmonary alveolar microlithiasis is a rare disorder, only 173 cases having been reported worldwide. Fifty two cases from Turkey are reported, 49 of which have previously been described only in Turkish publications. The mean age of the patients was 27 (SD 12) years, 34 were male, and 10 were symptomless. In 40 of the 52 cases diagnosis was confirmed histopathologically. Nineteen cases were diagnosed in siblings. This high rate suggests that pulmonary alveolar microlithiasis is a familial disease, which, though rare, is for unknown reasons most common in Turkey.