Inhaler Steroid Use Changes Oral and Airway Bacterial and Fungal Microbiome Profile in Asthma Patients.

INTRODUCTION: The full spectrum of bacterial and fungal species in adult asthma and the effect of inhaled corticosteroid use is not well described. The aim was to collect mouthwash and induced sputum samples from newly diagnosed asthma patients in the pretreatment period and in chronic asthma patients while undergoing regular maintenance inhaled corticosteroid therapy, in order to demonstrate the bacterial and fungal microbiome profile. METHODS: The study included 28 asthmatic patients on inhaler steroid therapy, 25 steroid-naive asthmatics, and 24 healthy controls. Genomic DNA was isolated from induced sputum and mouthwash samples. Analyses were performed using bacterial primers selected from the 16S rRNA region for the bacterial genome and "panfungal" primers selected from the 5.8S rRNA region for the fungal genome. RESULTS: Dominant genera in mouthwash samples of steroid-naive asthmatics were Neisseria, Haemophilus, and Rothia. The oral microbiota of asthmatic patients on inhaler steroid treatment included Neisseria, Rothia, and Veillonella species. Abundant genera in induced sputum samples of steroid-naive asthma patients were Actinomyces, Granulicatella, Fusobacterium, Peptostreptococcus, and Atopobium. Sputum microbiota of asthma patients taking inhaler steroids were dominated by Prevotella and Porphyromonas. Mucor plumbeus and Malassezia restricta species were abundant in the airways of steroid-naive asthma patients. Choanephora infundibulifera and Malassezia restricta became dominant in asthma patients taking inhaled steroids. CONCLUSION: The oral and airway microbiota consist of different bacterial and fungal communities in healthy and asthmatic patients. Inhaler steroid use may influence the composition of the oral and airway microbiota.

Real-world patient-level cost-effectiveness analysis of omalizumab in patients with severe allergic asthma treated in four major medical centers in Turkey.

AIMS: To evaluate the cost-effectiveness of standard-of-care treatment (SoC) to SoC in combination with omalizumab (OML + Soc) in patients with severe asthma using real-world prospective clinical data from four major medical centers in Turkey. MATERIALS AND METHODS: Between February 2018 and November 2019, a total of 206 patients with severe asthma, including 126 of whom were in the OML + SoC group and 80 in the SoC group, were followed for 12 months to evaluate their asthma status and quality of life. Cost data for this patient-level economic evaluation were sourced from the MEDULA database of the hospitals and expressed in Turkish Lira (₺). Efficacy data were obtained by means of Turkish versions of the Asthma Control Test for asthma status, the 5-level EQ-5D-5L version (EQ-5D-5L), and the Asthma Quality of Life Scale for quality of life. A Markov model with 2-week cycles was specified, comparing costs and treatment effects of SoC vs. OML + SoC over a lifetime from the Turkish payer perspective. RESULTS: Per-patient costs were ₺23,607.08 in the SoC arm and ₺425,329.81 in the OML + Soc arm, for a difference of ₺401,722.74. Life years (LY) and quality-adjusted life years (QALY) were 13.60 and 10.08, respectively, in the SoC group; and 21.26 and 13.35, respectively, in the OML + SoC group, for differences of 7.66 LYs and 3.27 QALYs. This yielded an incremental cost-effectiveness ratio of an additional ₺52,427.04 to gain 1 LY and an incremental cost-utility ratio of an incremental ₺122,675.57 to gain 1 QALY; the latter being below the ₺156,948 willingness-to-pay threshold for Turkey referenced by WHO. One-way and multivariate sensitivity analyses confirmed the base-case results. CONCLUSION: Whereas most economic evaluations are based on aggregate data, this independent cost-effectiveness analysis using prospective real-world patient-level data suggests that omalizumab in combination with standard of care is cost-effective for severe asthma from the Turkish public payer perspective.

What is the context? Severe asthma, a subset of difficult-to-treat asthma, refers to asthma that cannot be controlled despite adherence to optimized maximal therapy and treatment of contributing factors, or asthma that worsens when high-dose therapy is reduced.Omalizumab is the first biologic therapy approved for the treatment of allergic asthma. Its main role is to prevent the release of various inflammation factors that cause severe asthma episodes.Cost-effectiveness analysis is an economic method of determining how much more a new and better treatment costs relative to the current treatment in terms of how many life years (LY) and how many quality-adjusted life years (QALY) are gained with the new treatment. Cost-effectiveness results tell us how much more money is needed over the cost of the current treatment to achieve one additional LY, regardless of the quality of life, or one additional LY with good quality of life.No cost-effectiveness data obtained from actual clinical patient data are available for Turkey. What is new? Our study found that the addition of omalizumab to the current standard of care for severe asthma increases costs but also increases life years and quality-adjusted life years. The additional cost was less than what the World Health Organization assumes is reasonable for Turkey.This study used actual clinical patient data and noted that asthma patients in the omalizumab group used fewer health services, had a better clinical course, had a better quality of life, and lived longer with their disease under control.What is the impact? In severe asthmatic patients, adding omalizumab to standard-of-care, while more costly, yields better outcomes and is therefore cost-effective.The cost-effectiveness estimates fall within the margins of being cost-responsible. The Turkish public payer should strongly consider making omalizumab available to all eligible patients. This will enable working-age patients to work, and contribute to their families, while also strengthening the Turkish economy.

Economic Burden of Pediatric Asthma in Turkey: A Cost of Illness Study from Payer Perspective.

OBJECTIVES: To estimate economic burden of pediatric asthma in Turkey from payer perspective. MATERIALS AND METHODS: This cost of illness study was based on identification of per patient annual direct medical costs for the management of pediatric asthma in Turkey from payer perspective. Average per patient direct medical cost was calculated based on cost items related to outpatient visits, laboratory and radiological tests, hospitalizations and interventions, drug treatment and equipment, and co-morbidities/complications. RESULTS: Based on total annual per patient costs calculated for outpatient admission ($113.14), laboratory-radiological tests ($35.94), hospitalizations ($725.92), drug treatment/equipment ($212.90) and co-morbidities/complications ($144.62) cost items, total per patient annual direct medical cost related to management of pediatric asthma was calculated to be $1,232.53 from payer perspective. Hospitalizations and interventions (58.9%) was the main cost driver. Direct cost for managing controlled and uncontrolled pediatric asthma were calculated to be $530.17 [key cost driver: drugs/equipment (40.0%)] and $1,023.16 [key cost driver: hospitalization/interventions (59.0%)], respectively. CONCLUSION: Our findings indicate that managing patients with pediatric asthma pose a considerable burden to health economics in Turkey, with hospitalizations identified as the main cost driver and two-fold cost increment in case of uncontrolled disease.

Survey of Physician's Knowledge, Attitudes, and Practices Regarding Idiopathic Pulmonary Fibrosis in Turkey.

OBJECTIVES: The aim of this study is to evaluate the approaches of Turkish pulmonologists to the diagnosis and treatment of idiopathic pulmonary fibrosis (IPF) in daily clinical practice. MATERIALS AND METHODS: A questionnaire containing 38 questions about the IPF diagnosis and treatment was given to pulmonologists between January 22 and 29, 2018, and the data of 158 physicians who responded to the questionnaire were evaluated. RESULTS: This survey showed that the mean number of patients that physicians followed up and managed annually was 8.3 and 5, respectively. The mean symptom duration before the diagnosis was 9-12 months. Patients were seen on average by three physicians prior to confirmed diagnosis. Almost 80% of the physicians have an opportunity to access a pathologist and radiologist specialized in IPF. However, only 26% of them have an opportunity to access regular multidisciplinary meetings. Although antifibrotics were the most commonly prescribed drugs, approximately 10% of patients were prescribed steroids, N-acetylcysteine, and immunosuppressants. Most of the physicians (81%) were aware of international guidelines; however, the Turkish Thoracic Society IPF Diagnosis and Treatment Consensus Report was read by only 41% of them. CONCLUSION: This survey may lead to the IPF awareness in Turkey, and it may help to close the gaps regarding the diagnosis and treatment.

[Post-COVID-19 pulmonary sequla: longterm follow up and management]. / COVID-19 sonrasi akciger sekelleri: uzun dönem takip ve tedavi.

Though it has been 8 months since the beginning of COVID-19 pandemic, number of cases and deaths are still seriously increasing. We still don't have enough evidence about the prognosis of patients who had COVID-19 pneumonia. In long term follow up we wonder if they will have rapid FVC decline, widespread fibrosis in computed tomography, loss in quality of life or increased mortality that we experience in idiopathic pulmonary fibrosis, chronic hypersensitivity pneumonia or autoimmune interstitial lung diseases. However, in elderly patients less severe dysfunction or non-progressive-fibrosis can cause morbidity and mortality. Therefore, if we consider millions of people who are affected by COVID-19, even a rare complication can cause serious health problem in social scale. Because of the importance of this issue randomized controlled trials should be rapidly planned on post-COVID fibrosis, COVID associated thrombosis, risk factors, prevention and treatment (1). In this review, the frequency, clinical importance, prevention and treatment of possible long-term sequels of COVID-19 pneumonia (pulmonary fibrosis, pulmonary embolism and pulmonary hypertension) will be discussed.

The Prevalence of Asthma-COPD Overlap (ACO) Among Patients with Asthma.

OBJECTIVES: Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is defined as a persistent airflow limitation with features of both asthma and COPD. However, in Turkey, there are limited data about ACO. The aims of the present study were to determine the prevalence of ACO among patients with asthma, to compare the clinical characteristics of patients with ACO and asthma, and to determine the threshold values for the diagnosis of ACO. MATERIALS AND METHODS: The study group comprised 338 patients admitted to the outpatient clinics between 2010 and 2017 and who had undergone at least three pulmonary function tests within the last 2 years. Patients aged >40 years with a smoking history of >10 pack-years or biomass exposure, with at least three features of both diseases, and with reversible and persistent airflow limitation were diagnosed with ACO. The study is a retrospective study so we did not get informed concent. RESULTS: Asthma-chronic obstructive pulmonary disease overlap was diagnosed in 40 (11.8%) patients. Patients with ACO had fewer allergic comorbidities, worse spirometric parameters, and required higher doses of inhaled corticosteroids than patients with asthma only (p<0.05). No significant differences were observed between the groups regarding survival or number of hospitalizations and attacks (p>0.05). Threshold values were determined as age ≥57.5 years, smoking history ≥14 pack-years, and diagnosis at age ≥40.5 years. CONCLUSION: The frequency of ACO was observed to be very high in patients with asthma. In patients >57.5 years old, with a smoking history of >14.5 pack-years, and diagnosed with asthma at >40.5 years old, the probability of ACO diagnosis increases.

Comparison of clinical courses and mortality of connective tissue disease-associated interstitial pneumonias and chronic fibrosing idiopathic interstitial pneumonias.

Interstitial lung disease (ILD) is a common pulmonary manifestation of connective tissue diseases (CTD). Prognostic effect of radiological usual interstitial pneumonia (UIP) pattern in CTD-associated interstitial lung disease (CTD-ILD) is unknown. This study aimed to investigate the disease progression and mortality of patients with CTD-ILD and idiopathic interstitial pneumonias (IIP) including idiopathic pulmonary fibrosis (IPF) and idiopathic nonspecific interstitial pneumonia and the prognostic impact of the radiological UIP pattern on both disease groups. The medical records of 91 patients (55 with CTD-ILD and 36 with IIP) diagnosed with ILD at pulmonary medicine department, Faculty of Medicine, Gazi University from 2004 to 2014 were retrospectively reviewed. Patients included whose baseline high-resolution computed tomography (HRCT) scans showed either a UIP or non-UIP pattern. While 67.3% (n = 37) of CTD-ILD patients possessed UIP pattern, 38.9% (n = 14) of IIP patients had UIP pattern in HRCT. Respiratory functions including the forced expiratory volume in the first second (FEV1 ), functional vital capacity (FVC), and transfer coefficient for carbon monoxide (diffusing capacity of the lung for carbon monoxide [DLCO]) of IIP group at the time of diagnosis were significantly lower than CTD-ILD group (P = .007, P = .002, and P = .019, respectively). There was no significant survival difference between CTD-ILD and IIP by using the log-rank test (P = .76). Multivariate analysis revealed that UIP pattern in HRCT (Hazard ratio: 1.85; 95% Confidence interval = 1.14-3; P = .013), annual FVC (Hazard ratio: 0.521; 95% Confidence interval = 0.32-0.84; P = .007), and annual DLCO declines (Hazard ratio: 0.943; 95% Confidence interval = 0.897-0.991; P = .02) were independent risk factors for mortality in both CTD-ILD and IIP groups. We found that UIP pattern in HRCT and annual losses in respiratory functions were the main determinants of prognosis of ILDs either idiopathic or CTD-associated.

Cryptogenic and Secondary Organizing Pneumonia: Clinical Presentation, Radiological and Laboratory Findings, Treatment, and Prognosis in 56 Cases.

OBJECTIVES: Organizing pneumonia is an important disease that is associated with non-specific clinical findings and radiographic appearance. Our aim was to examine the clinical and radiological features, laboratory findings, diagnostic approach, and response to therapy in subjects with cryptogenic (COP) and secondary organizing pneumonia (SOP). MATERIALS AND METHODS: Patients' medical records were retrospectively reviewed between 2010 and 2016 in our hospital. We analyzed the symptoms, radiological features, pulmonary function tests, laboratory data, bronchoalveolar lavage findings, treatment, and prognosis. RESULTS: Thirty-seven patients were diagnosed with COP and 19 patients with SOP. The most common causes of SOP were determined as rheumatologic diseases. The most common symptoms were cough (71.4%) and dyspnea (66.1%). Bilateral symmetrical consolidations were the most prominent radiological appearance in both COP and SOP. The general radiographic findings were not different in COP and SOP. However, pulmonary lesions were located rather in the central (p=0.023) and middle (p=0.001) zones in patients with SOP. Corticosteroid (CS) therapy was administered to 34 (60.7%) patients. Two patients showed deterioration despite CS therapy. CONCLUSION: The clinical and radiographic findings, treatment response, prognosis were similar in patients with COP and SOP.

Diagnostic Yield of Transbronchial Biopsy in Comparison to High Resolution Computerized Tomography in Sarcoidosis Cases

This study aimed to evaluate the diagnostic yield of fiberoptic bronchoscopic (FOB) transbronchial biopsy and its relation with quantitative findings of high resolution computerized tomography (HRCT). A total of 83 patients, 19 males and 64 females with a mean age of 45.1 years diagnosed with sarcoidosis with complete records of high resolution computerized tomography were retrospectively recruited during the time period from Feb 2005 to Jan 2015. High resolution computerized tomography scans were retrospectively assessed in random order by an experienced observer without knowledge of the bronchoscopic results or lung function tests. According to the radiological staging with HRCT, 2.4% of the patients (n=2) were stage 0, 19.3% (n=16) were stage 1, 72.3% (n=60) were stage 2 and 6.0% (n=5) were stage 3. This study showed that transbronchial lung biopsy showed positive results in 39.7% of the stage I or II sarcoidosis patients who were diagnosed by bronchoscopy. Different high resolution computerized tomography patterns and different scores of involvement did make a difference in the diagnostic accuracy of transbronchial biopsy (p=0.007).

Birt-Hogg-Dube Syndrome with a Novel Mutation in the FLCN Gene.

BACKGROUND: Birt-Hogg-Dube syndrome (BHDS) is an autosomal dominant disease characterized by hair follicle hamartomas, kidney tumors, and spontaneous pneumothorax; its cause is a heterozygous mutation in the FLCN gene. Colorectal polyps and carcinoma have also been reported in BHDS. FLCN mutations can be detected in patients with isolated primary spontaneous pneumothorax (PSP), so PSP may present as part of BHDS. The aim of this report is to enhance awareness that patients presenting with spontaneous PSP should be evaluated for FLCN mutations. MATERIALS AND METHODS: A 44-year-old woman with PSP and her parents were analyzed for FLCN mutations. One of the patient's paternal aunts had a PSP and two of her paternal aunts had colon cancer diagnosed at early ages. RESULTS: A novel in-frame deletion in the FLCN gene, c.932_933delCT (P311Rfs*78), was detected in the proband and in her unaffected father. CONCLUSIONS: We recommend that molecular analysis of the FLCN gene be performed in patients with PSP and their families, and that mutation carriers be examined for kidney and colon tumors.

Asthma phenotypes in Turkey: a multicenter cross-sectional study in adult asthmatics; PHENOTURK study.

BACKGROUND AND AIMS: To evaluate asthma phenotypes in patients with asthma from different regions of Turkey. METHODS: A total of 1400 adult asthmatic patients (mean (SD) age: 44.0 (13.9) years, 75% females) from 14 centers across Turkey were included in this study and a standard questionnaire was applied between the time period of February 2011-January 2012. RESULTS: The disease onset ≥ 40 years of age was higher percentage in obese vs. normal/overweight patients and nonallergic vs. allergic patients (P < 0.01). The percentage of patients who had FEV1 values over 80% was higher in allergic than nonallergic and normal/overweight than obese patients (P < 0.01). Uncontrolled asthmatics have more severe disease (P < 0.01). There were more frequent hospital admissions in nonallergic and uncontrolled asthmatics (P < 0.01). Chronic rhino-sinusitis was the leading comorbid disorder in normal/overweight and allergic asthma, while gastroesophageal reflux disorder was more frequent in nonallergic and uncontrolled asthma (P < 0.01). Asthma control rate was the highest (39.0%) in patients from Marmara region among all geographical regions (P < 0.05). CONCLUSION: In conclusion, our findings revealed existence of clinical/trigger related phenotypes based on BMI, allergic status, control level and geographical region with more frequent respiratory dysfunction and/or adverse health outcomes in uncontrolled, obese and nonallergic phenotypes.

18 F-FDG uptake in focal organising pneumonia mimicking bronchial carcinoma.

BACKGROUND AND AIMS: Organising pneumonia (OP) is not a well-known cause of increased 18 F-FDG uptake, and the relationship of the increased 18 F-FDG uptake to clinical parameters has not been clearly identified. This study aims to assess the role of positron emission tomography-computed tomography (PET-CT) for the diagnosis of focal organised pneumonia that may mimic malignity because of mass-like lesions on the radiological images it causes. METHODS: Among 40 patients of whom histopathological exams were consistent with OP, medical records of 14 focal OP patients diagnosed with surgical biopsy were evaluated retrospectively. RESULTS: There were 10 male (71.4%) and 4 female (28.6%) patients. The mean age at the time of diagnosis was 57.2 ± 11.7 years, ranging from 38 to 85 years. Nine subjects (64.3%) were smokers. Eleven patients (78.5%) had symptoms, the remaining 3 patients (21.5%) were asymptomatic. Three patients (21.3%) had a history of malignancy. Focal lung lesion was initially detected by chest radiography in 10 patients (71.4%) and by computed tomography (CT) scan in all patients. CT scan showed a single lesion in 12 (85.7%) patients. The lesions were located in the right lung of the half of patients (50%) and in the left lung of the other half. The median diameter of the lesions was 3.4 cm (range, 1.8-6.0 cm). PET with 18 F-FDG was performed in all patients, and hypermetabolic activity of the focal lung lesion was demonstrated in all cases. The median values of maximum standardized uptake value was 3.5 ± 2.7 (min 2.1-max 13.1). CONCLUSION: Focal OP is a discrete form of OP that is associated with unifocal lesions on radiological images, and it can easily mimic lung cancer because of positivity on PET scans. There are no specific findings of PET scan for the diagnosis of OP.

Effects of Inspiratory Muscle Training in Subjects With Sarcoidosis: A Randomized Controlled Clinical Trial.

BACKGROUND: Respiratory muscle weakness occurs in sarcoidosis and is related to decreased exercise capacity, greater fatigue, dyspnea, and lower quality of life in sarcoidosis patients. The effects of inspiratory muscle training in this population have not been comprehensively investigated so far. This study was planned to investigate the effects of inspiratory muscle training on exercise capacity, respiratory and peripheral muscle strength, pulmonary function and diffusing capacity, fatigue, dyspnea, depression, and quality of life in subjects with sarcoidosis. METHODS: This was a prospective, randomized, controlled, and double blind study. Fifteen sarcoidosis subjects (treatment group) received inspiratory muscle training at 40% of maximal inspiratory pressure (P(Imax)), and 15 subjects (control group) received sham therapy (5% of P(Imax)) for 6 weeks. Functional and maximal exercise capacity, respiratory and peripheral muscle strength, pulmonary function and diffusing capacity, fatigue, dyspnea, depression, and quality of life were evaluated. RESULTS: Functional (P < .001) and maximal exercise capacity (P = .038), respiratory muscle strength (P(Imax) [P < .001] and P(Emax) [P = .001]), severe fatigue (P = .002), and dyspnea perception (P = .02) were statistically significantly improved in the treatment group compared with controls; no significant improvements were observed in pulmonary function and diffusing capacity, peripheral muscle strength, fatigue, depression, and quality of life between groups after inspiratory muscle training. CONCLUSIONS: Inspiratory muscle training improves functional and maximal exercise capacity and respiratory muscle strength and decreases severe fatigue and dyspnea perception in subjects with early stages of sarcoidosis. Inspiratory muscle training can be safely and effectively included in rehabilitation programs. (ClinicalTrials.gov registration NCT02270333.).

A Case of Sarcoidosis Associated With Anti-Tumor Necrosis Factor Treatment.

Sarcoidosis is a systemic chronic granulomatous disease of unknown etiology. It predominantly involves the lungs but can affect many organs or tissues in the body, such as the lymphatic system, skin, eyes, and liver. Typical histopathological lesions are noncaseating granulomas in the affected organ or tissue. Indications, type of treatment, and duration of sarcoidosis treatment is currently debated. Despite studies showing that anti-tumor necrosis factor-α (TNF-α) treatment can successfully be used in refractory sarcoidosis, there are some case reports regarding the development of sarcoidosis with these agents. There have been reports of 47 anti-TNF-associated cases of sarcoidosis until 2012. The patient is a 54-year-old Caucasian male. During routine examinations of the patient who had been followed for psoriasis vulgaris for 20 years and who had been on several anti-TNF regimens thereafter, new pulmonary pathologies due to sarcoidosis were detected. We present here a case of sarcoidosis that developed after infliximab treatment and showed obvious radiologic regression with discontinuation of treatment. During anti-TNF treatment, it should be kept in mind that autoimmune and granulomatous diseases may develop and particular care should be given to patient follow-ups.

Respiratory Bronchiolitis-Associated Interstitial Lung Disease in Childhood: New Sequela of Smoking.

Childhood interstitial lung diseases are rare disorders of largely unknown etiology characterized by variable types and degrees of parenchymal inflammation. Disease spectrum and prognosis considerably from those in adults. Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) is a well-described entity occurring almost exclusively in adults who are current heavy cigarette smokers. We describe an 11-year-old boy with failure to thrive, dry cough, and exertional dyspnea for 1 year who was diagnosed with RB-ILD due to heavy passive smoking exposure. Although RB-ILD is well defined in smoking adults, there are no reports in the English literature in nonactive smokers, especially in childhood.

[Acute exacerbation in COPD and asthma]. / KOAH ve astimda atak.

Chronic obstructive pulmonary disease (COPD) and asthma are airway diseases with acute exacerbations. Natural course of both disease are affected by exacerbations. COPD exacerbations may be caused by infections and other causes; indoor and outdoor pollution, cardiovascular diseases, asthma-COPD overlap syndrome, COPD- obstructive sleep apnea syndrome, pulmonary embolism, gastro-oesophageal reflux, anxiety-depression, pulmonary hypertension. Exposure to triggering factors, viral infections, treatment insufficiency may cause asthma exacerbations. Smoking cessations, prevention of infections, long-acting anticholinergics, long-acting 2 agonists, inhaled corticosteroids, phosphodiesterase-4 inhibitors, mucolytics, prophilactic antibiotics can be effective on the prevention of COPD exacerbations. Asthma exacerbations may be decreased by the avoidance of allergens, viral infections, occupational exposures, airpollution, treatment of comorbid diseases. Effective treatment of asthma is required to prevent asthma exacerbations. Inhaled steroids and combined treatments are the most effective preventive therapy for exacerbations. Patient education and cooperation is an element of the preventive measures for asthma attacks. Compliance to therapy, inhalation techniques, written asthma plans are required. The essential of COPD and asthma exacerbation treatment is bronchodilator therapy. Steroids are also implemented to the therapy, targeting the inflammation. Specific treatments of the cause (infection, airpollution, pulmonary embolism etc.) should be administered.

A Case of Langerhans Cell Histiocytosis with Atypical Radiological Presentation.

Pulmonary Langerhans cell histiocytosis (PLCH) is a rare interstitial lung disease characterized by the accumulation of histiocytes within the airspaces or parenchyma of the lung. It almost always occurs in smokers between the ages of 20 and 40. Bronchoscopic interventions, such as transbronchial biopsy (TBB) and bronchoalveolar lavage (BAL), should be performed before other more invasive procedures, but their diagnostic yield is lower. TBB is frequently non-diagnostic due to inadequate sampling. BAL cellular analysis may show alveolar macrophage predominance, and the detection of >5% of CD1a-positive cells in BAL fluid is highly suggestive and specific for the disease; however, this increase is not observed frequently. Surgical lung biopsy is the most definite modality for diagnosis. Smoking cessation must be recommended for all patients. The prognosis for most patients is relatively good, particularly if longitudinal lung function testing shows stability. Here, we presented a 48-year-old smoker with an unusual and unexpected radiological presentation.

[Asthma-COPD overlap syndrome]. / Astim-KOAH overlap Sendromu.

Asthma and chronic obstructive pulmonary disease (COPD) are common lung diseases characterized by chronic airway inflammation and airway obstruction. Among patient with COPD and asthma; there is a group of patients with an overlap between clinical, functional characteristics and airway inflammation patterns, named "Asthma-COPD Overlap Syndrome" (ACOS). ACOS is a syndrome characterized by reversible but persistant airflow limitation (postbronchodilator FEV1/FVC < 70%) which has some features of both asthma and COPD. ACOS should be suspected in a patient > 40 years, with smoking history, previous asthma diagnosis or history of childhood asthma who has persistant airflow limitation and reversible ariway obstruction (defined by an increase of > %12 of FEV1 pred or increase of FEV1 > 200 mL after inhalation of 400 mcg salbutamol or 1000 mcg terbutaline). The prevalence for ACOS has been reported 11-55% in different case series to date and increases by age and is more frequent in females in different age groups. Patients with ACOS are younger than COPD patients and older than asthma patients. Frequent and severe exacerbations and related hospitalization and emergency room visits are common in ACOS and this causes an impaired quality of life. Current recommendations of guidelines for pharmacologic treatment of ACOS have been composed of a combination with optimal COPD and asthma treatment. Future therapeutic approaches should be based on endotypes. Clinical phenotype and underlying endotype driven clinical studies may be the base of ACOS guidelines.

[Treatment of severe asthma: expert opinion]. / Agir astim tedavisi: uzman görüsü

Severe asthmatics account 10% of the all asthmatic population. Those asthmatics whose disease is inadequately controlled account for up to half of the cost for asthma, because they have more emergency room visits, more hospital admission and greater absenteeism from work. New therapeutic options were tried in those patients whose asthma was uncontrolled with standart high dose inhaled corticosteroid and long acting beta-2 agonsit combination therapy. In this paper taking into account the conditions of our country, current literature was reviewed and treatment options was discussed and graded recommendations are made for daily clinical practice in patients with severe treatment-refractory asthma.

Asthma control test via text messaging: could it be a tool for evaluating asthma control?

INTRODUCTION: Originally, the Asthma Control Test (ACT) was designed for English-speaking patients using a paper-and-pencil format. The Turkish version of the ACT was recently validated. This article compares the paper-and-pencil and web-based texting formats of the Turkish version of the ACT and evaluates the compatibility of these ACT scores with GINA-based physician assessments of asthma control. METHODS: This multicentre prospective study included 431 asthma patients from outpatient clinics in Turkey. The patients were randomized into a paper-and-pencil group (n = 220) and a text messaging group (n = 211). Patients completed the ACT at Visit 1, after 10 ± 2 days, and at 5 ± 1 week to demonstrate the reliability and responsiveness of the test. At each visit, physicians assessed patients' asthma control levels. RESULTS: The ACT administered via texting showed an internal consistency of 0.82. For the texting group, we found a significant correlation between the ACT and physician assessments at Visit 1 (r = 0.60, p < 0.001). The AUC was 0.87, with a sensitivity of 78.0% and a specificity of 77.5% for a score of ≤19 for screening "uncontrolled" asthma in the texting group. CONCLUSION: When the Turkish version of the ACT was administered via either the paper-and-pencil or text messaging test, scores were closely associated with physician assessments of asthma control.