Spondylodiscitis presenting as pleural effusion in a geriatric female: A case report.

Pleural effusion is a frequently seen medical problem caused by pulmonary and non-pulmonary diseases. Spondylodiscitis is a very rare cause of pleural effusion and is typically diagnosed based on clinical, laboratory, microbiological and radiological findings. The low incidence and different clinical presentations of Spondylodiscitis make its diagnosis and treatment challenging. We present the case of a 78-year-old female who was initially admitted due to chest pain and upon chest radiography, was found to have pleural effusion; and eventually diagnosed with spondylodiscitis.

Chronic thromboembolic pulmonary hypertension in patients with persistent chest symptoms after acute pulmonary embolism.

OBJECTIVE: This study aimed to analyze the role of chronic thromboembolic pulmonary hypertension (CTEPH) in patients with persistent chest symptoms after acute PE. METHODS: Patients aged between 18 and 80 years who were followed up for acute PE were screened for chest symptoms which persisted after the anticoagulation treatment. Patients suffering other types of pulmonary hypertension (PH) or metastatic malignancies were excluded in this study. Demographic and functional data of patients included this study were collected. The patients underwent transthoracic echocardiography and ventilation/perfusion (VQ) scans. Also, invasive hemodynamic studies were done to patients with intermediate/high probability of VQ scans. RESULTS: Of the 140 patients screen for this study, 29 patients (Female/Male=16/13) with mean age of 56.1±11.2 years and follow-up time of 35.1±17.7 months met the inclusion criteria. The mean systolic pulmonary artery blood pressure (sPAP) on transthoracic echocardiography was 28.9±4.9 mm Hg (range=20-40 mm Hg). Furthermore, intermediate or high probability of VQ scans was detected in 2 patients, who were subsequently diagnosed with CTEPH (6.9%) via right heart catheterization. CONCLUSION: CTEPH was diagnosed at a low rate in patients with persistent chest symptoms after the anticoagulation treatment for PE. CTEPH is still an elusive entity, which requires a multidisciplinary and invasive approach.

Comparison of Artificial Neural Networks and Logistic Regression for 30-days Survival Prediction of Cancer Patients.

INTRODUCTION: A machine learning technique that imitates neural system and brain can provide better than traditional methods like logistic regression for survival prediction and create an algorithm by determining influential factors. AIM: To determine the influential factors on survival time of palliative care cancer patients and to compare two statistical methods for better prediction of survival. METHODS: One-year data is gathered from the patients that we followed in the palliative care clinic of our hospital (2017-2018) (n = 189). All data were retrospectively evaluated. After descriptive statistics, we used Pearson and Spearman correlations for parametric and non-parametric variables. The Artificial Neural Networks (ANN) and logistic regression model were applied to parameters which have a significant correlation with short survival. RESULTS: Significantly correlated variables with short survival were Palliative Performance Scale (PPS), Edmonton Symptom Assessment System (ESAS), Karnofsky Performance Scale (KPS), brain, liver, and distant metastasis, hemogram parameters, cero-reactive protein (CRP) and albumin (ALB). ANN model showed 89.3% prediction accuracy while the logistic regression model showed 73.0%. ANN model achieved a better AUC value of 0.86 than logistic regression model (0.76). DISCUSSION: There are several prognostic evaluation tools such as PPS, KPS, CRP, albumin, leukocytes, neutrophil were reported several studies as survival-related parameters in logistic regression models, also. Many studies compare ANN with logistic regression. When we evaluated these parameters totally, we observed the same relations with survival then we used the same parameters in the ANN model. The effectivity of the survival prediction models can be improved with the use of ANN. CONCLUSION: ANN provides a more accurate estimation than logistic regression. ANN model is an important statistical method for survival prediction of cancer patients.

Relation of Warrick Score and Polysomnographic Parameters in Patients with Interstitial Lung Disease.

BACKGROUND Obstructive sleep apnea (OSA) is often reported in connection with interstitial lung disease. As yet, there is insufficient data on the association of OSA severity parameters with lung involvement. We purposed to assess the frequency of OSA in our study group and to investigate the relationship between radiological involvement and OSA severity parameters. MATERIAL AND METHODS The study included 79 patients with interstitial lung disease who underwent spirometry, a carbon monoxide diffusion test (DLCO), high-resolution computed tomography, and polysomnography. The data were analyzed using SPSS 22 software. RESULTS Of the 79 patients, 53 patients (67.1%) had OSA, and there was a negative correlation between DLCO and the mean time spent with oxygen saturation levels below 90% (r=-0.686, P=0.001). The Warrick score was used as an indicator of the extent and severity of pulmonary involvement and was positively correlated with the apnea-hypopnea index, oxygen desaturation index, and the mean time spent with oxygen saturation below 90% (r=0.275, P=0.014; r=0.264 P=0.019; r=0.235, P=0.038). CONCLUSIONS In our study, a significant relationship was found between the Warrick score and the OSA severity parameters, as determined by polysomnography. Polysomnographic examinations might be useful, especially in patients with a Warrick score greater than 15, to avoid possible complications.

Relationship of radiometabolic biomarkers to KRAS mutation status and ALK rearrangements in cases of lung adenocarcinoma.

PURPOSE: Rapid diagnosis of genetic mutations is important for targeted therapies such as EGFR tyrosine kinase inhibitors. KRAS mutation and ALK rearrangement are also important in determining treatment. The purpose of our study was to evaluate the diagnostic value of 18F-FDG PET to predict KRAS mutation and ALK rearrangement in order to determine the frequency of these genetic markers in our lung adenocarcinoma cases and contribute to forthcoming meta-analysis studies. METHODS: A total of 218 patients with lung adenocarcinoma (EGFR analyzed) who were seen at our clinic between 2012 and 2014 were included in the study. The results of the 18 F-FDG-PET scans for each patient were retrospectively recorded with the associated medical documents. ALK rearrangements were analyzed in 166 of the 218 patients, while 50 of the 218 patients were analyzed for KRAS mutational status. SPSS 15.0 for Windows was used for statistical analysis. RESULTS: FDG avidity was higher in cases with KRAS mutations and ALK rearrangements than those without, but the difference was not significant. ALK rearrangements were more common in younger, female, and nonsmoking patients with lung adenocarcinoma. CONCLUSIONS: The small numbers of KRAS mutations and ALK rearrangements are the limitation of this study for evaluation of diagnostic imaging. The frequency of these genetic alterations was as reported in the literature. We believe that our work will contribute to future meta-analysis.

Relationship of Radiometabolic Biomarkers to KRAS Mutation Status and ALK Rearrangements in Cases of Lung Adenocarcinoma.

Purpose Rapid diagnosis of genetic mutations is important for targeted therapies such as EGFR tyrosine kinase inhibitors. KRAS mutation and ALK rearrangement are also important in determining treatment. The purpose of our study was to evaluate the diagnostic value of 18F-FDG PET to predict KRAS mutation and ALK rearrangement in order to determine the frequency of these genetic markers in our lung adenocarcinoma cases and contribute to forthcoming meta-analysis studies. Methods A total of 218 patients with lung adenocarcinoma (EGFR analyzed) who were seen at our clinic between 2012 and 2014 were included in the study. The results of the 18 F-FDG-PET scans for each patient were retrospectively recorded with the associated medical documents. ALK rearrangements were analyzed in 166 of the 218 patients, while 50 of the 218 patients were analyzed for KRAS mutational status. SPSS 15.0 for Windows was used for statistical analysis. Results FDG avidity was higher in cases with KRAS mutations and ALK rearrangements than those without, but the difference was not significant. ALK rearrangements were more common in younger, female, and nonsmoking patients with lung adenocarcinoma. Conclusions The small numbers of KRAS mutations and ALK rearrangements are the limitation of this study for evaluation of diagnostic imaging. The frequency of these genetic alterations was as reported in the literature. We believe that our work will contribute to future meta-analysis.

To what extent and why are COPD and Willis-Ekbom disease associated?

AIM: Willis-Ekbom disease (RLS/WED) is common in chronic obstructive pulmonary disease (COPD). Patients with RLS/WED have poorer quality of sleep and more fatigue and depressive symptoms. The prevalence of RLS/WED in patients with COPD has been reported to vary between 29.1 and 36.8 %. However, during exacerbation, the prevalence can increase up to 54 %. These rates are higher than those seen in general population. We have not enough knowledge regarding the association between RLS and COPD. In this study, we aimed to determine the frequency of RLS in patients with stable COPD without comorbid conditions. In addition, we also aimed to determine possible related causative factors. METHOD: We included 80 COPD patients without comorbid conditions who presented to our outpatient clinic between April 2013 and September 2013 for RLS/WED evaluation. Three cases that have polyneuropathy and one case that refused undergoing electromyography (EMG) examination were excluded from the study. Demographic data, P-A chest X-rays, pulmonary function tests (PFT), biochemical parameters (including hemogram), and dyspnea scales were evaluated for each patient. In addition, the RLS/WED rating scale and Epworth Sleep Scale (ESS) were applied. Further, each patient diagnosed with RLS/WED underwent a detailed neurological examination (performed by a neurologist) and an EMG examination to rule out polyneuropathy. RESULTS: Out of 76 COPD cases included in our study, 26.3 % (n = 20) were diagnosed with RLS/WED (mean age 60.4 ± 7.5 years, 20 males). The cases with RLS/WED had significantly lower body mass index (BMI) than cases without RLS/WED (p = 0.009). There were no significant differences between cases with and without RLS/WED with respect to PFT, dyspnea scales, and arterial blood gas values. However, ESS was significantly different (p = 0.016). There were no significant differences in RLS/WED scores and mean hs-CRP levels between COPD stages (p = 0.424; p = 0.518, respectively), while ESS was significantly different (p = 0.016). ESS was significantly higher in stage B COPD than in stages A and D (p = 0.005, p = 0.008, respectively). Based on our model, we found that exacerbations and iron binding capacity (UIBC) were predictive factors for RLS/WED (p < 0.100) CONCLUSION: RLS/WED is a common disease in cases with stable COPD. Despite our hypothesis suggesting that the prevalence of RLS/WED in COPD is related with systemic inflammation, we did not find a significant association between hs-CRP and COPD cases with RLS/WED. However, we did find that UIBC is a predictive factor for the development of RLS/WED. Nonetheless, further studies are needed to understand the relationships between UIBC, low BMI, and the development of RLS/WED in COPD.

Contribution of ¹8Fluorodeoxyglucose positron emission tomography uptake and TTF-1 expression in the evaluation of the EGFR mutation in patients with lung adenocarcinoma.

AIM: The aim of this study is to evaluate the diagnostic value of PET-CT scan for the prediction of EGFR mutation status and the contribution of TTF-1 expression to PET-CT scan. METHODS: We retrospectively studied 218 cases with a diagnosis of pulmonary adenocarcinoma between 2012-2014 which underwent EGFR analysis, TTF-1 and PET-CT before treatment. RESULTS: The EGFR mutation was present in 28.9% (n= 63) of cases. TTF-1 positivity was 66.9% (n= 105). Standardized uptake value (SUV max) was 16.7 ± 6.8 in EGFR mutant type, 13.8 ± 7.6 in cases having no EGFR mutations. According to our evaluations, high SUVmax is positively correlated with EGFR mutation status. TTF-1 expression in multivariate analysis strengthens the accuracy of detecting an EGFR mutation. CONCLUSION: PET-CT FDG uptake may, together with TTF-1 expression, help diagnosis in lung adenocarcinoma cases when evaluating for EGFR mutation status.

Translation strategy for the qualification of drug-induced vascular injury biomarkers.

Drug-induced vascular injury (DIVI) is a common preclinical toxicity usually characterized by hemorrhage, vascular endothelial and smooth muscle damage, and inflammation. DIVI findings can cause delays or termination of drug candidates due to low safety margins. The situation is complicated by the absence of sensitive, noninvasive biomarkers for monitoring vascular injury and the uncertain relevance to humans. The Safer And Faster Evidence-based Translation (SAFE-T) consortium is a public-private partnership funded within the European Commission's Innovative Medicines Initiative (IMI) aiming to accelerate drug development by qualifying biomarkers for drug-induced organ injuries, including DIVI. The group is using patients with vascular diseases that have key histomorphologic features (endothelial damage, smooth muscle damage, and inflammation) in common with those observed in DIVI, and has selected candidate biomarkers associated with these features. Studied populations include healthy volunteers, patients with spontaneous vasculitides and other vascular disorders. Initial results from studies with healthy volunteers and patients with vasculitides show that a panel of biomarkers can successfully discriminate the population groups. The SAFE-T group plans to seek endorsement from health authorities (European Medicines Agency and Food and Drug Administration) to qualify the biomarkers for use in regulatory decision-making processes.

The assessment of high sensitivity C-reactive protein as a systemic marker in moderate asthma patients and changing levels by inhaled corticosteroids.

OBJECTIVES: To see if high-sensitivity C-reactive protein levels increase even in the early stages of asthma, and to evaluate if corticosteroid therapy affects the levels in asthma patients. METHODS: The case-control pilot study was conducted at Yedikule Chest Disease and Surgery Education and Research Hospital, Turkey, from February to April 2011. Patients newly diagnosed with asthma who reported symptoms that occurred six months before diagnosis were included in the study.The protein levels were measured pre-treatment and one month post-treatment. In addition, pulmonary function test and total Immunoglobulin-E measurements were taken and the prick test was performed. Statistical analysis was done using SPSS 15. RESULTS: There were 15 cases; 8 (53%) females and 7 (47%) males. Besides, there were 19 Controls; 9 (47%) females and 10 (53%) males. The mean age of the Cases was 29.13+/-10.30 years, while for the Controls it was 28.9+/-5.35 years. The difference was not statistically significant (p<0.54). The difference in protein levels pre and post-treatment was not significant. However, a higher level in the pre-treatment period was found compared to the Controls. Posttreatment levels in the Cases were not significantly different than the Controls. CONCLUSION: Elevated high-sensitivity C-reactive protein levels in asthmatic patients may indicate an increased risk for cardiovascular disease. Future studies in asthma patients should focus on this relationship.

Immunohistochemical expression of telomerase in patients with non-small cell lung cancer: prediction of metastasis and prognostic significance.

AIM: To detect telomerase reverse transcriptase (TERT) expression in tissue and metastatic and non-metastatic lymph node samples from patients with non-small cell lung cancer; to evaluate whether TERT expression is correlated with pathological and clinical features, and/or patient survival times; to determine differences between TERT expression in metastatic and non-metastatic lymph nodes. PATIENTS AND METHODS: Tumor tissue samples from 17 patients with squamous cell lung cancer and 11 patients with adenocarcinoma diagnosed between 2003 and 2004 were included in this study. All patients were diagnosed at our hospital and had samples stored in the pathology archive. Additionally, dissected lymph node samples, with and without metastases, were studied. Telomerase Gene Tex, Inc, Irvine, CA USA (TERT (2C4) antibody), Universal Kit (Lab Vision, Newmarket, UK) were used for immunohistochemical staining. Statistical analyses were performed using SPSS 17.0 statistical software. RESULTS: TERT was positive in 18/28 of the samples, regardless of the histological tumor type. There was no significant correlation between TERT expression in lymph nodes with metastasis and clinical stage, histological type, tumor differentiation, or survival time. CONCLUSION: TERT expression may be used as a target for therapy. It may also be helpful in predicting metastasis but not in predicting survival time.

Gastroesophageal reflux disease in our asthma patients: the presence of dysphagia can influence pulmonary function.

BACKGROUND: The prevalence of Gastroesophageal Reflux Disease (GERD) in Turkey is reported as 11.6%. Studies of pulmonary function in asthmatics have demonstrated a correlation between lung resistance and the occurrence of spontaneous gastroesophageal reflux. Few studies have included measures of lung diffusing capacity for carbon monoxide. The aim of this study is to assess whether asthma patients had worse lung function and gas diffusion according to diversity of GERD symptoms they concurrently experienced. The secondary aim of the study is to determine the frequency and different faces of GERD in our asthma patients compared to healthy controls. METHODS: Sixty consecutive asthma patients evaluatd at the pulmonary specialty outpatient clinic were included in the study. The control group included 60 healthy volunteers who had normal pulmonary function and routine laboratory tests. A modified version of a self-reported questionnaire developed by Locke and associates at the Mayo Clinic was conducted face-to-face with consecutive asthma patients and control subjects. Pulmonary function measurements were taken using spirometry. DLCO (mL/dk/mmHg) and DLCO/VA (DLCO adjusted according to alveolar volume) were measured using a single-breath technique. Statistical analyses were performed using the SPSS 17.0 statistical software. RESULTS: DLCO and DLCO/VA were significantly lower in asthma patients who had dysphagia symptoms. Frequent and significant acid regurgitations were seen in 28.33% (n = 17) of patients in the study group and 6.7% (n = 4) of patients in the control group. Severe, troublesome heartburn symptoms were reported by 28.2% (n = 17) of patients in the study group and 16.7% (n = 10) of subjects in the control group. Dysphagia was detected in 38.3% (n = 23) of all asthma cases and in 1.7% (n = 1) of the subjects in the control group. CONCLUSIONS: There were many faces of gastroesophageal reflux disease in our asthmatic patients. Dysphagia was the only GERD symptom influencing on pulmonary function tests, while gastroesophageal reflux symptoms and nocturnal awakening attacks were common in this study.

Are we aware of restless legs syndrome in COPD patients who are in an exacerbation period? Frequency and probable factors related to underlying mechanism.

A few previous studies have reported that the patients with chronic obstructive pulmonary disease (COPD) have a 29.1% to 36.8% frequency of restless legs syndrome (RLS). In this study, we observed RLS symptoms in patients experiencing COPD exacerbation to better understand the relationship between the many clinical parameters of COPD and the presence of RLS and to attract the attention of specialists on the association between the two conditions. Twenty-two male patients in COPD exacerbation; 17 healthy individuals were evaluated in this study. The patients were evaluated using the 2003 RLS symptom criteria outlined by the International Restless Legs Syndrome Study Groups (IRLSSG). The Pittsburgh Sleep Quality Index and Epworth daytime sleepiness scale were used to assess the sleep quality of patients. The RLS symptoms were correlated with blood levels of laboratory and clinical parameters. Statistical analyses were performed using SPSS 17.0 statistical software packet. The Pittsburgh Sleep Quality Index and Epworth daytime sleepiness scale scores were increased in COPD patients and correlated significantly with RLS symptoms. It was found that 54.5% of COPD patients with acute exacerbations were observed to have RLS symptoms. The Pittsburgh Sleep Quality Index was significantly higher in COPD patients with RLS symptoms compared to COPD patients without RLS symptoms (p < 0.05). We did not observe any significant difference in the previously reported metabolic and clinical parameters associated with RLS in COPD patients with and without RLS. RLS symptoms increase during COPD exacerbation and lead to decreased sleep quality.

Recent aspects of vasculitis and future direction.

Vasculitis is pathologically identified as specific cellular inflammation, vessel destruction, and tissue necrosis. Current classifications of vasculitis such as the Chapel Hill Classification (CHCC) and American College of Rheumatology (ACR) guidelines are not sufficiently adequate for clinicians to diagnose vasculitis. The biomarkers that are currently in clinical use such as PR3-ANCA and MPO-ANCA, only help in diagnosing small vessel vasculitis and their sensitivity and specificity are not sufficient. However, recent developments related to the pathogenesis and etiopathogenesis of vasculitis have the potential to contribute to new and improved biomarkers. The determination of diverse roles of ANCA and synergistic effects of infection, genetic, environmental factors and drugs on pathogenesis is quite important. The demonstration of a new autoantibody directed to hLAMP-2 and the resemblance to some microbial structures, in addition to the determination of the possible roles of hepatitis B and C on vasculitis are important findings. These hints may lead to new biomarker developments, providing a better method to diagnose vasculitis. The evidence on T cell immunity as circulatory and lesional will likely contribute to the development of new drugs for vasculitis.

Erosive esophagitis worsens reflux signs and symptoms in asthma patients without affecting pulmonary function tests.

OBJECTIVES: To determine whether erosive esophagitis (EO) worsens reflux signs and symptoms and affects pulmonary function test in asthma patients. METHODS: Sixty asthma patients with gastroesophageal and laryngopharyngeal reflux symptoms were included. Spirometry, reversibility test, esophagogastroscopy, laryngoscopy, and esophagogastroscopic biopsies were conducted. RESULTS: EO was diagnosed in 25% (n = 15) of the patients. The remaining 45 patients were placed into the non-erosive esophagitis (NEO) group. Of the 15 EO patients, grade 1 esophagitis was identified in 75% (n = 9), grade 2 in 12.5% (n = 3), and grade 3 in 12.5% (n = 3). Pulmonary function test results were not significantly different between the EO and NEO groups. Gastroesophageal and laryngopharyngeal reflux symptoms such as regurgitation, dysphagia, dyspnea, globus sensation, dysphonia, and sore throat were more frequent in EO patients than in the NEO group. The reflux finding score (RFS) was 7.33 and 4.55 in EO and NEO patients, respectively (p < .001). Posterior commissure hypertrophy was the most common laryngoscopic finding in both of the groups followed by diffuse laryngeal edema, erythema, and pseudosulcus. CONCLUSIONS: Gastroesophageal and laryngopharyngeal reflux symptoms were more frequent in EO patients than in the NEO group. The laryngoscopic findings of laryngopharyngeal reflux were more severe and the RFS was significantly higher in EO patients than in NEO patients. The presence of EO seems to be associated with an increase in reflux without affecting pulmonary function as EO did not cause a significant decrease in pulmonary function tests.

Treatment of endoluminal typical carcinoid tumor with bronchoscopic techniques.

Surgical treatment of typical bronchial carcinoid tumors varies from bronkoskopic excision to major resective procedures. Typical carcinoid tumor was detected in 29 year old man patient who were admitted to our clinic with hemoptysis and dyspnea. Typical carcinoid tumor was treated with exsicion after argon plasma coagulation by bronchoscopic techniques. It should not be forgotten that bronchoscopic approach and simple excision is an effective and safe procedure for the treatment of typical bronchial carcinoid tumors in selected cases like polypoid type lesions.