The frequency of obstructive sleep apnea in patients with primary Sjogren's syndrome.

INTRODUCTION: There is a lack of information about the frequency of obstructive sleep apnea (OSA) in primary Sjogren's syndrome (pSS). Using all-night polysomnography (PSG), this study aimed to investigate the frequency of OSA in pSS and the factors affecting the frequency of OSA in this condition.  METHODS: Consecutive patients with pSS who presented to the Collagen Tissue Diseases follow-up polyclinic of the Department of Chest Diseases between 1 April 2019 and 31 December, 2020, were included in the study. Demographic characteristics, chronic diseases, smoking history in pack-years, anthropometric data, Epworth Sleepiness Scale score, pulmonary function test parameters, current thorax computed tomography findings, and PSG data were recorded. The control group was created by the retrospective screening of patients admitted to the sleep polyclinic and who underwent PSG but did not have pSS. RESULTS: OSA was detected in 37 (84%) of 44 patients with pSS who underwent PSG. Of 37 patients with OSA, 25 (68%) had moderate or severe OSA. Snoring and witnessed apneas, REM%, snoring index, and maximum apnea and maximum hypopnea duration were statistically significantly lower in the pSS group compared with the control group (p < 0.001, p = 0.003, p = 0.025, p = 0.001, p = 0.028, and p = 0.035, respectively). CONCLUSION: The frequency of OSA in patients with pSS was 84%, with a decrease in REM%. Although a correlation between symptoms suggesting OSA and the presence of radiological lung involvement, spirometry, and DLCO values with OSA could not be demonstrated, physicians are recommended to be attentive for the presence of OSA in all patients with pSS and to investigate OSA using PSG.

Annual FEV1 Loss in Patients with Noncystic Fibrosis Bronchiectasis and Affecting Factors.

OBJECTIVES: Bronchiectasis is a chronic respiratory disease characterized by sputum production, cough, and several bronchial infections. Lung function is an important parameter to evaluate and study in patients with bronchiectasis. This study aimed to evaluate the annual changes in forced expiratory volume in one second (FEV1) and related factors in patients with with noncystic fibrosis bronchiectasis. METHODS: A total of 529 patients who were diagnosed as having bronchiectasis using computed tomography and followed at the bronchiectasis unit of the Cerrahpasa Medical Faculty at Istanbul University between 1996 and 2018 were included in this retrospective study. A total of 153 patients were included in the study. RESULTS: The mean age of the patients was 58.6 ± 16.8 years and 61% (n = 93) were female. The annual change of FEV1 and forced vital capacity was -39 ± 82 (minimum: -585, maximum: 355, median: -26) mL and - 44 ± 91 (minimum: -517, maximum: 303, median: -31) mL, respectively. There was no correlation in FEV1 decline between those with and without Pseudomonas colonization (P = 0.65). No correlation was found between the etiologic factors and the decline of FEV1. A correlation existed only between the first FEV1 and the decline of FEV1 (for the first FEV1%, P = 0.038 [R = -0.17]; for the first FEV1 [mL] P = 0.026 [R = -0.18]). CONCLUSIONS: An annual mean FEV1 loss of 39 mL was found in adult patients with noncystic fibrosis bronchiectasis. The annual mean FEV1 decline was found to be associated with the baseline FEV1 value. Physicians should exercise caution in this regard in patients with bronchiectasis with low FEV1 values.

Increased frequency of obstructive sleep apnea in the patients with systemic sclerosis.

INTRODUCTION: Sleep problems, including obstructive sleep apnea (OSA), profoundly affect quality of life in patients with systemic sclerosis (SSc). This study aimed to determine the prevalence of OSA in patients with SSc and the factors affecting OSA. METHODS: Consecutive patients with SSc lung involvement who were referred to the "Outpatient Service for Interstitial Lung Disease" in our university hospital between 2015 and 2017 were included in the study. All patients completed the Epworth Sleepiness Scale (ESS) and underwent examination including body mass index (BMI), measurement of waist circumference, upper respiratory tract examination, and polysomnography (PSG). Spirometry, carbon monoxide diffusion test (DLCO), and 6-min walking distance were also performed. RESULTS: Of 38 patients, mean age 51.3 ± 11.6 years, 35 were women (92%). Mean apnea-hypopnea index (AHI) was 11 ± 15 (median 5.5) and prevalence of OSA was 58%. Mild OSA was found in 13 (34%) of patients, moderate OSA in 6 (16%), and severe OSA in 3 (8%). Significant relationships were found between age (p = 0.02), waist circumference (p = 0.01), presence of witnessed apneas (p = 0.005), and presence of OSA. CONCLUSIONS: Compared with the general population, the prevalence of OSA is increased in women with SSc. Patients with older age, those with increased waist circumference, and those reporting witnessed apneas should be studied for OSA.

Clinical challenges in elderly asthma.

INTRODUCTION: Understanding the difference of elderly asthma is essential to provide better healthcare for this vulnerable population. The aim of this study was to evaluate the differences between young and elderly asthma patients. MATERIALS AND METHODS: This real-life study was designed as a cross-sectional analysis. All data collected with structured web based asthma program. In sum, 373 (89.9%) young asthma (YA, age < 65) and 42 (10.1%) elderly asthma (EA, age < 65) patients followed at least one year and compared statistically. RESULT: Cough is found higher in EA (p< 0.01) despite lower smoking rate in EA (p< 0.001). Allergic rhinitis and allergic conjunctivitis were more common in YA (p< 0.05, p< 0.01) which is consistent with higher allergy rate in YA (p< 0.05). On the other hand, diabetes and hypertension were determined significantly higher in EA (p< 0.01, p< 0.01). 52.4% of EA patients were found to have low diffusion capacity (DLCO < 80%). Although EA patients use combined therapies with inhaled corticosteroids and long acting beta agonists more than YA patients (p< 0.01), both emergency room visit (ERV) and hospitalization ratios are founded significantly higher in EA (p< 0.001, p< 0.001). CONCLUSIONS: EA patients were presented with cough in general. They possess an increased risk of hypertension, diabetes and low levels of diffusion capacity. ERV and hospitalization ratios have founded higher despite higher usage of combined therapies.

Factors affecting the tuberculosis risk in patients receiving anti-tumor necrosis factor-α treatment.

BACKGROUND: Tumor necrosis factor (TNF)-α inhibitors are known to increase the risk of tuberculosis (TB). OBJECTIVES: To examine the factors associated with an increased risk of TB in patients receiving anti-TNF-α treatment (aTNF-α-T). METHOD: Of 3,094 patients who received aTNF-α-T between 2003 and 2013, a total of 1,964 subjects with a follow-up time longer than 6 months were identified and included in this retrospective analysis. Potential risk factors for the development of TB in patients receiving aTNF-α-T were evaluated. RESULTS: Of the 1,964 patients, 1,009 (51%) were male and 955 (49%) were female, with a mean age of 39.7 ± 13.9 years. The primary conditions requiring aTNF-α-T included ankylosing spondylitis (n = 875), rheumatoid arthritis (n = 711), Behçet's disease (n = 83), and others (n = 295). Sixteen patients [8 (50%) males and 8 (50%) females; 5 (31.2%) with pulmonary TB and 11 (68.8%) with extrapulmonary TB] developed TB, with a corresponding TB incidence of 466/100,000. No significant associations were found between age, gender, smoking history, pack-years of smoking, isoniazid (INH) chemoprophylaxis, type of anti-TNF-α agent, use of other immunosuppressive drugs, and the risk of TB (p > 0.05). Multivariate logistic regression analysis showed a significantly higher risk of TB in patients diagnosed with Behçet's disease, and a significantly lower risk of TB in patients with a tuberculin skin test wheal ≥10 mm in diameter (p < 0.05). CONCLUSION: aTNF-α-T is associated with an increased risk of pulmonary or extrapulmonary TB, even when follow-up protocols and INH chemoprophylaxis are implemented, and TB often develops in the later stages of treatment. The risk of TB was higher in patients with Behçet's disease and lower in patients who had a strong tuberculin skin test reaction.

Survival in progressive systemic sclerosis with pulmonary involvement: a single-center experience in Istanbul, Turkey.

The objective of the current study was to determine survival and factors that affect survival in progressive systemic sclerosis (SSc) with pulmonary involvement. A total of 102 SSc patients with pulmonary involvement, diagnosed between 1994 and 2008, enrolled into the study. Pulmonary involvement was defined based on the presence of interstitial changes on high-resolution CT (HRCT). Demographical, clinical, radiological, and laboratory data of the patients were found from patient records and were used for the evaluation of survival. The mean age of the patients at diagnosis was 50 ± 12 years. In follow-up, 22 (21.5%) patients were deceased. The mean age of the patients at death was 55 ± 12 years. Seventy-eight percent of known causes of mortality were related to pulmonary complications. After any initial systemic manifestation of disease, the mean survival was 447 ± 27 months and 5, 10, 15, and 20 year survival rates were 99, 92, 83, and 72%, respectively. The mean survival after initial pulmonary manifestation was 269 ± 23 months and 5, 10 and 15 year survival rates were 91, 73 and 57%, respectively. Mean survival was 113 ± 5 months, and 5- and 10-year survival rates after the lung involvement detected with HRCT were 85 and 66%, respectively. Pulmonary artery hypertension, disease onset after the age of 40, and honeycombing on HRCT were associated with poor survival. Our data suggest that pulmonary involvement is the most important determinant factor for poor prognosis in patients with SSc. Therefore, echocardiography, pulmonary function tests, and HRCT should be performed in early stages of the disease for early diagnosis of pulmonary artery hypertension and lung involvement before irreversible vascular and interstitial changes exist.

Investigating the Differences in Polysomnography Results Evaluated According to the Recommended and Alternative Hypopnea Criteria Utilized in the Evaluation of Polysomnography.

OBJECTIVE: The criteria of hypopnea recommended by the American Academy of Sleep Medicine until 2012 was 3% desaturation and 50% decline in the signal amplitude. The recommended and alternative criteria for hypopnea were determined as 3% desaturation accompanied by a 30% decline in the signal amplitude and 4% desaturation accompanied by a 30% decline in the amplitude by the 2013 update of the guideline was published by the American Academy of Sleep Medicine in 2012. The objective of our study was to investigate to what degree scoring of hypopneas has great importance in the diagnosis and severity grading of obstructive sleep apnea syndrome according to different criteria. MATERIAL AND METHODS: The present study was designed as a retrospective study in which the results of the polysomnography of 62 patients were recorded after evaluation according to 3 different hypopnea criteria. Criteria 1, criteria 2, and criteria 3 were accepted as a 3% drop in SaO2 accompanied by a 30% decline in the amplitude, as a 4% drop in SaO2 accompanied by a 30% decline in the amplitude, and as a 3% drop in SaO2 accompanied with a 50% decline in the amplitude, respectively. RESULTS: Statistically significant differences were determined between criteria 1 and criteria 2, criteria 1 and criteria 3, and criteria 2 and criteria 3 regarding the numbers of hypopneas. CONCLUSION: For the same polysomnography, evaluations with different accepted hypopnea criteria cause different polysomnography results.

Extrapulmonary involvement in patients with sarcoidosis in Turkey.

BACKGROUND AND OBJECTIVE: Extrapulmonary sarcoidosis is common, and is almost always associated with concomitant thoracic involvement. Extrapulmonary manifestations vary on the basis of gender, age at presentation and ethnicity. The aim of this study was to investigate extrapulmonary involvement in patients with sarcoidosis in Turkey. METHODS: This study was conducted by Turkish Thoracic Society Clinical Problems Study Group. New cases of sarcoidosis between 1 June 2004 and 31 May 2006 were recorded on electronic case record forms sent to all potential investigators and information about extrapulmonary involvement was collected. RESULTS: One hundred and nineteen of 293 patients (83 female, 36 male, mean age = 45 ± 12 years) had extrapulmonary involvement in this study (40.6%). The median time to diagnosis was 6 months and this was longer than patients with just thoracic sarcoidosis (P = 0.001). Extrapulmonary symptoms were present in 181 (61.8%) patients, and skin lesions, arthralgia and back pain were the commonest (33.4%, 20.8% and 16.4%, respectively). Incidence of organ involvement was independent of age with the exception of ocular involvement, which was higher in those under the age of 40 years (P = 0.007). CONCLUSIONS: Skin and peripheral lymph node involvement were the most common sites of extrapulmonary involvement and ocular involvement was more common in those under the age of 40 years in patients with sarcoidosis in a Turkish population.

Clinical presentations and diagnostic work-up in sarcoidosis: a series of Turkish cases (clinics and diagnosis of sarcoidosis).

Sarcoidosis is an idiopathic granulomatous disease. It usually affects the lung. The diagnosis may be problematic since the known causes of granulomatous inflammation must be excluded. This multicenter study aimed to evaluate the clinical presentations and diagnostic approaches of sarcoidosis. The study protocol was sent via internet, and the participants were asked to send the information (clinical, radiological and diagnostic) on newly diagnosed sarcoidosis cases. 293 patients were enrolled within two years. Pulmonary symptoms were found in 73.3% of the patients, and cough was the most common one (53.2%), followed by dyspnea (40.3%). Constitutional symptoms were occured in half of the patients. The most common one was fatigue (38.6%). The most common physical sign was eritema nodosum (17.1%). The most common chest radiograhical sign was bilateral hilar lymphadenomegaly (78.8%). Staging according to chest X-ray has revealed that most of the patients were in Stage I and Stage II (51.9% and 31.7%, respectively). Sarcoidosis was confirmed histopathologically in 265 (90.4%) patients. Although one-third of the bronchoscopy was revealed normal, mucosal hyperemi (19.8%) and external compression of the bronchial wall (16.8%) were common abnormal findings. The 100% success rate was obtained in mediastinoscopy among the frequently used sampling methods. Transbronchial biopsy was the most frequently used method with 48.8% success rate. Considering sarcoidosis with its most common and also rare findings in the differential diagnosis, organizing the related procedures according to the possibly effected areas, and the expertise of the team would favour multimodality diagnosis.

Decreasing Rate of Unknown Bronchiectasis Etiology: Evaluation of 319 Adult Patients with Bronchiectasis.

OBJECTIVE: Bronchiectasis can have several causes, but there are only a limited number of studies about the prevalence of these causes. Most of the studies in adults are from previous years. This study aimed to identify etiologies in adult patients with bronchiectasis. MATERIAL AND METHODS: Between January 1996 and June 2015, data from 319 patients admitted to a specialized bronchiectasis clinic were analyzed. Diagnoses were confirmed using high-resolution or multislice computed tomography and were retrospectively evaluated. RESULTS: Of the 319 patients, 187 (58.6%) were women and 132 (41.4%) were men. The mean age was 49.0±17.4 (range 15-83) years. The mean duration of illness was 19.5±14.9 years. There were several common etiologies: (1) post-infections (215; 67.5%, 70 of the 215 patients had tuberculosis); (2) obstructive lung diseases (28, 8.8%); (3) defects in mucociliary clearance (13, 4.2%); (4) connective tissue diseases (8, 2.4%); (5) immunodeficiency (5, 1.5%); (6) structural lung conditions (1, 0.3%); and (7) obstruction of a single bronchus (1, 0.3%). No causes could be established in 41 (12.9%) patients. CONCLUSION: Despite developments in antibiotic therapy and vaccination programs, the most common etiology for bronchiectasis is post-infectious conditions as observed in previous years. However, with improvements in diagnostic tests and procedures, the rate of unknown etiologies has dropped from ≥50% to 12.9%.

Comparison of the effectiveness of cyclophosphamide and rituximab treatment in patients with systemic sclerosis-related interstitial lung diseases: a retrospective, observational cohort study.

OBJECTIVES: To compare the effectiveness of cyclophosphamide and rituximab in the treatment of patients with systemic sclerosis with pulmonary involvement (SSc-ILD). METHODS: Symptoms and the respiratory function parameters of 34 patients receiving cyclophosphamide and 27 patients receiving rituximab for at least 24 months between 1996 and 2018 were compared. RESULTS: It was observed that symptoms including cough, Raynaud's phenomenon, digital ulceration, diarrhea, and dysphagia, but not dyspnea, recovered statistically significantly more in the rituximab group (p = 0.004, p = 0.001, p = 0.006, p = 0.005, and p < 0.001, respectively; for dyspnea p = 0.11). When differences in FVC and FVC% values were compared with baseline, it was found that there was a statistically significant increase in FVC (mL) (p = 0.02) and FVC% (p = 0.002) values after 12 months of treatment in patients receiving cyclophosphamide compared with those receiving rituximab. When differences in DLCO and DLCO% values from baseline were compared, a statistically significant increase was seen in DLCO values after 15 and 24 months (p = 0.003 and p = 0.048, respectively) of treatment, also in DLCO% values after 15 and 18 months (p = 0.008 and p = 0.01, respectively) of treatment in patients receiving rituximab compared with those receiving cyclophosphamide. CONCLUSION: It was observed that both cyclophosphamide and rituximab treatments were effective in controlling dyspnea and worsened pulmonary function in SSc-ILD. The effect of cyclophosphamide is more prominent on FVC and rituximab is more effective on DLCO. Key Points • Both cyclophosphamide and rituximab treatments were effective in controlling dyspnea and worsened pulmonary function in SSc-ILD. • The effect of cyclophosphamide is more prominent on FVC and rituximab is more effective on DLCO.

Maternal and Fetal Problems in Patients with Non-Cystic Fibrosis Bronchiectasis During Pregnancy.

OBJECTIVE: To detect the maternal and fetal problems experienced by patients with non-cystic fibrosis (non-CF) bronchiectasis during pregnancy. MATERIAL AND METHODS: A total of 185 women aged over 18 years with medical records available, who were diagnosed as having non-CF bronchiectasis and followed in the outpatient clinic for bronchiectasis, were interviewed by phone between November 1, 2019 and December 31, 2019. Forty-seven women who accepted to participate, were able to understand and answer the survey, and had experienced at least 1 pregnancy, were included in the study, The survey questions were read and the answers were recorded. The same survey was administered to a control group of 95 women. RESULTS: It was found that the number of patients experiencing an increase in at least 1 of the symptoms of cough, sputum production, and dyspnea during pregnancy, and the number of visits to emergency departments for respiratory conditions, were statistically significantly higher (P < .001 and P < .001, respectively), and the rate of live births was significantly lower (P = .009) in the non-CF bronchiectasis group compared with the control group. No significant difference was found between the groups in the number of miscarriages, preterm births, cesarean section, extra visits to the obstetrics department, and the presence of anomalies in the infants. CONCLUSION: Among patients with non-CF bronchiectasis, it should be kept in mind that an increase may be seen in respiratory symptoms and the number of emergency department visits during pregnancy, and a decrease may be seen in the ratio of live births. These patients should be followed closely for these issues and measures should be taken accordingly.

The Frequency of Obstructive Sleep Apnea in Patients with Non-cystic Fibrosis Bronchiectasis.

OBJECTIVE: Interruption or reduction in airflow and desaturation is a theoretically expected result in bronchiectasis accompanied by excessive secretions in the airways, bronchial wall thickening, and destruction of the wall structure. The same mechanism of interruption or reduction in airflow and desaturation is valid for obstructive sleep apnea (OSA). However, data on the association of bronchiectasis with OSA are scarce. We aimed to investigate the frequency of OSA and related parameters in patients with non-cystic fibrosis bronchiectasis (NCFB). MATERIAL AND METHODS: All 43 consecutive patients who presented to the outpatient clinic for bronchiectasis follow-up between January 1, 2018 and January 1, 2019 were included. The polysomnography (PSG) data of the 43 patients were reviewed. Groups of patients with and without OSA, as detected using PSG, were compared in terms of clinical, demographic, and polysomnographic parameters. RESULTS: The mean age of the 43 patients was 50 ± 15 years; 28 (65.2%) were female. OSA was detected in 24 (55.8%) of 43 patients, of whom 14 (32.6%) had mild, 5 (11.6%) had moderate, and 5 (11.6%) had severe OSA. Three (7.0%) patients were REM-dependent and 7 (16.3%) were position-dependent. When evaluated using logistic regression analysis, REM percentage (16.8% vs. 11.8%, P = .03) and presence of witnessed apnea (33.3% vs. 15.7%, P = .01) were observed to be significantly higher in the patients with OSA. The age factor was found at the significance limit (P = .05). CONCLUSION: The frequency of OSA in patients with NCFB is 55.8%. Investigating OSA using PSG is important in patients with NCFB, especially at advanced ages.

Excess Mortality During COVID-19 Pandemic in Istanbul.

OBJECTIVE: Epidemiological studies have shown that mortality owing to the coronavirus disease 2019 (COVID-19) could be under-reported under different conditions. Excess mortality analysis is suggested as a useful tool in estimating the impact of the disease. MATERIAL AND METHODS: Mortality data between January 01 and May 18, 2020, were analyzed to evaluate the excess mortality owing to COVID-19 in Istanbul, the city most affected by the pandemic in Turkey. The average weekly percentage changes in the number of deaths in 4 previous years were compared with those in the year 2020 using excess mortality analysis. RESULTS: The number of deaths in Istanbul was significantly higher in 2020 (p=0.001), with a 10% weekly increase between the 10th and 15th weeks, which started to decrease until the 20th week. The excess mortality found during the study period was 4,084 deaths, higher than the officially reported COVID-19 mortality. CONCLUSION: Our findings demonstrated that mortality owing to COVID-19 could be higher than the official figures reported by health authorities.

The role of typical and atypical pathogens in acute exacerbations of chronic obstructive pulmonary disease.

OBJECTIVES: The exact role of Mycoplasma pneumoniae, Chlamydophila pneumoniae, and Legionella pneumophila in the development of chronic obstructive pulmonary disease exacerbations remains to be elucidated. This study was conducted to identify nonspecific and atypical pathogens associated with acute exacerbations of COPD. MATERIALS AND METHODS: Between February 2013 and February 2015, 107 patients were analyzed. Sixty-nine comprised the inpatient and 38 comprised the outpatient treatment group. RESULTS: When nonspecific culture results were taken into consideration only a causative organism could be detected in 46.7% of the patients. The detection rate increased to 85.1% with the additional use of polymerase chain reaction (PCR), direct fluorescent antibody (DFA) test, and culture methods. More than one causative agent was responsible for COPD exacerbation in 53.3% of patients: two agents in 37.3%, three agents in 15%, and four agents in 0.9%. H. influenzae was detected in 63 (58.9%) patients, S. pneumoniae in 57 (53.2%), P. aeruginosa in 15 (14.0%), and L. pneumophila in 11 (10%). L. pneumophila was the more commonly isolated agent in the inpatient group (P = 0.002). Patients receiving continuous oxygen therapy and noninvasive mechanical ventilation were more likely to have an exacerbation associated with P. aeruginosa (P = 0.008 and P = 0.009, respectively). CONCLUSION: The additional use of DFA for Legionella and multiplex PCR in combination with nonspecific microbiological culturing methods greatly improves the ability to identify infectious agents in acute exacerbations of COPD. There should be a high index of suspicion for P.aeruginosa as a causative organism, particularly in subjects receiving continuous oxygen therapy and/or using NIV and L. pneumophila should certainly be taken into consideration in severe COPD exacerbations.

[First report of three culture confirmed human Lyme cases in Turkey]. / Türkiye'de ilk kez etkenleri kültürde uretilen uç insan lyme hastaligi olgusu.

Lyme disease which is caused by the spirochete Borrelia burgdorferi, is a multisystemic disease that involves skin, joints, cardiovascular and central nervous system, leading to chronic inflammatory response and late complications. First lyme cases have been reported after 1990's in Turkey and the spirochete was isolated from the tick vectors. In this case series three human Lyme cases confirmed with not only serological tests but also growth in Barbour-Stoenner-Kelly medium were presented for the first time in Turkey. Two of these three cases were residents in Istanbul while the third one has acquired the infection in USA (imported case). First case was a previously healthy 46 years old male, admitted to the state hospital with the complaints of diarrheae, chills, nausea, vomiting, cough, sputum production and widespread myalgias. The patient was a chronic alcohol consumer with a history of frequent visits to the forest areas. The laboratory test results revealed hepatonephritis-like clinical picture and pulmonary involvement. Leptospira IgM and Borrelia IgM antibodies were detected in the serum by ELISA and both of the agents were isolated in the blood cultures of the patient. This case was then diagnosed as Lyme disease with leptospirosis co-infection. The second case was a 32 years old female who suffered from Bell's palsy for the last 15 days. Cranial magnetic resonance imaging showed a nodular lesion at globus pallidus. Since the patient had a history of tick-bite, further testing was done for Lyme disease. Borrelia IgM and IgG antibodies were found negative, however, Borrelia was isolated from the cerebrospinal fluid sample. The third patient was a 68 years old female who had recently travelled to USA and exposed to a tick-bite in a recreational area. She suffered from nausea, vomiting, myalgia and cutaneous lesions compatible with erythema chronicum migrans. Samples taken from the skin lesions revealed growth of Borrelia. As far as the current literature is concerned, these were the first three culture proven cases of Borrelia in Turkey. These three cases supported the presence of Lyme disease in Turkey and indicated that the disease could present itself in various clinical pictures.

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.

COVID-19 Pandemic and the Global Perspective of Turkish Thoracic Society.

It has been more than 3 months now since the first case of COVID-19 was reported in Turkey. Globally, the number of confirmed cases and deaths reached 9,653,048 and 491,128 respectively, as reported by 216 countries by June 27, 2020. Turkey had 1,396 new cases, 194,511 total cases, and 5,065 deaths by the same date. From the first case until today, the Turkish Thoracic Society (TTS) has been very proactive in educating doctors, increasing public awareness, undertaking academic studies, and assisting with public health policies. In the present report, social, academic, and management perspectives of the pandemic are presented under appropriate subtitles. During this critical public health crisis, TTS has once again demonstrated its readiness and constructive stance by supporting public health, healthcare workers, and the environment. This review summarizes the perspective of TTS on each aspect of the COVID-19 pandemic and casts light on its contributions.

A difficult case: sarcoidosis of the middle ear.

Sarcoidosis is a common multisystemic granulomatous disorder affecting several organs and tissues. However, the respiratory tract is the region commonly involved in more than 90% of patients, and the middle ear is a direct extension of it. In spite of this, direct middle ear and/or mastoid involvement of sarcoidosis is more rarely seen. Otological involvement may mimic a number of other diseases of the ear; sarcoidosis will probably not be considered prospectively. In addition, pulmonary symptoms of the patients often go unnoticed for some time. We report a patient presenting with hearing loss and tinnitus as the primary manifestation of sarcoidosis of the ear.

Changes in inflammatory mediators as a result of intermittent hypoxia in obstructive sleep apnea syndrome.

BACKGROUND: Inflammation plays an important role in obstructive sleep apnea syndrome (OSAS). The objective of this study was to investigate the relationship of serum C-reactive protein (CRP), pentraxin-3 (PTX-3), procalcitonin (ProCT), interleukin-33 (IL-33) and its soluble receptor ST2 (sST2) with the syndrome severity and to show theirs importance as biomarkers. METHODS: This study comprises a total of 84 identical (sex and age wise) cases. Full-night polysomnography was performed in each patient. OSAS diagnosis and severity index being based on the widely used criterion known as Apnea Hypopnea Index(AHI). Subgroups were as follows: 24(AHI < 5) controls, 28 mild-moderate OSAS(AHI 5-30) and 32 severe OSAS(AHI > 30). RESULTS: PTX-3, IL-33 and sST2 receptors were significantly higher in OSAS groups than the control group (P < .001). However, both CRP and ProCT levels were similar in all subjects. There was a positive correlation between PTX-3 and BMI (r = 0.446; P < .01), ODI (r = 0.555; P < .01), IL-33 (r = 0.348; P = .001) and sST2 (r = 326; P = .002), while there was a negative correlation with minimum SaO2 (r = -0.672; P < .01) in patient group. PTX-3 as a predictor of OSAS showed highest specificity (%91.7) and sensitivity (%91.7) (P < .001). CONCLUSIONS: PTX-3 can be a new indicator reflecting the inflammatory state in patients with OSAS. Since patients with OSAS could have more hypoxic state during sleep, we found higher PTX-3 level in those patients and a negative correlation between PTX-3 and minimum SaO2 , which could explain that PTX-3 levels can increase with the severity of disease. Our results suggest that PTX-3 as an inflammatory biomarker may play a crucial role as an indicator of syndrome severity in OSAS.