[Assessing the knowledge in primary health care following an educational course structured in the context of GARD chronic airway diseases national control program]. / Türkiye kronik hava yolu hastaliklari önleme ve kontrol programi (GARD Türkiye) birinci basamakta çalisan hekim egitimi bilgi degerlendirme sonuçlari.

INTRODUCTION: Chronic obstructive pulmonary diseases are common causes of disease in the community and account for considerable percent of the caseload in primary health care facilities. For this reason, it is important to question and improve the knowledge of primary health care physicians. This study is designed to assess the level of knowledge for bronchial asthma and COPD of the primary healthcare physicians, both before and immediately after an educational course structured in the context of GARD Chronic Airway Diseases National Control Program. MATERIALS AND METHODS: The participating physicians attended an intensive educational course on asthma and COPD. Twenty five item questionnaires for asthma and COPD were administered to the participants both before and immediately after the end of the course. Contribution of education to the level of knowledge was investigated by comparing the percentages of the correct answers in the pre-and post-test. RESULT: From 11 different cities, 1817 and 1788 primary health care physician were attended to the asthma and COPD educations, respectively. The accuracy rate of ≥ 75% was obtained from only 4 questions in pre-test asthma questionnaire. On the contrary, in 15 questions the accuracy rate was < 50%. The mean accuracy rate for the whole asthma test was 45.8%, and this rate raised to 69.6% after education course. The accuracy rate of ≥ 75% could not be obtained from any of the questions in pre-test COPD questionnaire. On the contrary, in 19 questions the accuracy rate was < 50%. The mean accuracy rate for the whole asthma test was 42.0%, and this rate raised to 71.3% after education course. CONCLUSIONS: It has been shown that, in primary care settings, the level of knowledge in asthma and COPD should be enhanced and that this increase can be achieved with an education course.

COPD phenotypes in a lung cancer screening population.

BACKGROUND AND AIMS: COPD (chronic obstructive pulmonary disease) is a very heterogeneous disease, and phenotypic categorization of a high-risk population has many potential benefits. The present study uses a symptom questionnaire, low-dose computed tomography (LDCT) and pulmonary function tests (PFT) to phenotypically subgroup a high-risk population. METHODS: Study group consisted of current or former smokers who underwent lung cancer screening with LDCT as a subgroup of Pittsburgh Lung Screening Study. In addition to LDCT, PFT and a symptom query questionnaire were obtained from each patient. RESULTS: The study group consisted of 3183 subjects (age 50-79) subdivided into eight groups according to presence of symptoms, obstruction on PFT and presence of emphysema on LDCT. A total of 501 (15.7%) subjects were asymptomatic, with no airflow obstruction or evidence of emphysema. There were 866 (27.2%) subjects with both obstruction on PFT and emphysema on LDCT, but only 660 (20.7%) had symptoms. Five hundred thirty (16.6%) of the subjects had no emphysema on LDCT but had obstruction on PFT, although only 370 (11.6%) had symptoms. Four hundred seventy-four (14.9%) of subjects had emphysema on LDCT, but no airflow obstruction, with 312 (9.8%) symptomatic. Finally, 812 (25.5%) of subjects had no evidence of airflow obstruction on PFT or emphysema on LDCT, but had symptoms. CONCLUSION: Combining LDCT with PFT and a comprehensive questionnaire allows subgroup classification of COPD phenotypes in a high-risk population and may lead to earlier intervention and an improved framework for future studies.

Serum neuron-specific enolase and S-100ß levels as prognostic follow-up markers for oxygen administered carbon monoxide intoxication cases.

Serum neuron-specific enolase (NSE) and S-100ß levels are considered novel biochemical markers of neuronal cell injury. In this study, the initial and post-treatment levels of NSE and S-100ß were compared in carbon monoxide (CO) poisoning patients, who received normorbaric oxygen (NBO) or hyperbaric oxygen (HBO) therapy. Forty consecutive patients with acute CO poisoning were enrolled in this prospective, observational study. According to their clinical symptoms and observations, twenty patients were treated with NBO, and the other twenty with HBO. Serum S-100ß and NSE levels were measured both at time of admission and 6 h later (post-treatment). Serum NSE and S-100ß values decreased significantly in both of the therapeutic modalities. The initial and post-treatment values of NSE and S-100ß in NBO or HBO patients were comparable. A clear negative correlation was observed between the decrease of NSE and S-100ß levels and initial blood carboxyhemoglobin levels. In conclusion, the present results suggested the use of serum S-100ß and NSE levels as indicators for brain injury. Due to the significant increase of their values with oxygen therapy, they may also be useful as prognostic follow-up markers. However, the current findings reflected no difference between the efficacy of NBO or HBO therapy.

The utility of tumor markers CA 125, CA 15-3, and CA 19-9 in assessing the response to therapy in pulmonary and pleural tuberculosis.

AIM: Both of the diagnosis and treatment evaluation are time-consuming conditions in patients with pulmonary and pleural tuberculosis. The aim of this study was to establish the validity of tumor markers CA 125, CA 15-3, and CA 19-9 in the diagnosis of pulmonary and pleural TB and to verify the success of the treatment protocol. PATIENTS AND METHODS: The levels of tumor markers CA 125, CA 15-3, and CA 19-9 were measured before and after treatment in 67 TB patients, 54 of whom had pulmonary TB and 13 of whom had pleural TB. All values were compared with the results of a healthy control group of 44 subjects. RESULTS: CA 125 and CA 15-3 levels were significantly high when compared with those of the healthy control group and there was a significant decrease in both tumor marker levels after treatment in patients with pulmonary TB (P < 0.001 and P < 0.004, respectively). However, the difference found in CA 19-9 levels before and after treatment in patients with pulmonary TB was not statistically significant (P < 0.08). When the CA 125, CA 15-3, and CA 19-9 values of the pulmonary TB group before treatment were compared with that of the healthy control group, the results were statistically significant in all parameters except CA 19-9 (P < 0.001, P < 0.001, and P < 0.09 for CA 125, CA 15-3, and CA 19-9, respectively). In the patients with pleural TB, CA 125, CA 15-3, and CA 19-9 values did not change significantly after treatment. CONCLUSION: The authors suggest that CA 125 and CA 15-3 tumor markers may be important for verification of the success of treatment protocol in pulmonary TB, as the differences found for these tumor markers between the pre- and the posttreatment periods are statistically significant.

Efficacy of serum chitotriosidase activity in early treatment of patients with active tuberculosis and a negative sputum smear.

BACKGROUND: The results of sputum culture for Mycobacterium tuberculosis must be awaited in most cases, which delays the start of treatment in patients with sputum smear-negative pulmonary tuberculosis. We investigated whether plasma chitotriosidase activity is a strong marker for early diagnosis of tuberculosis in patients for whom a bacillus smear is negative and tuberculosis culture is positive. METHODS: Clinical, radiological, and laboratory features were evaluated in 75 patients, 17 of whom were diagnosed as having active tuberculosis by negative acid-fast bacillus smear and positive culture, 38 as having sequel tuberculosis which was radiologically and microbiologically negative, and 20 who served as healthy controls. Serum chitotriosidase activity levels were measured in both cases and controls. RESULTS: The mean age of the cases with active pulmonary tuberculosis, cases with sequel lesions, and controls was 23 ± 2.4 years, 22 ± 1.7 years, and 24 ± 2.1 years, respectively. Serum chitotriosidase levels were 68.05 ± 72.61 nmol/hour/mL in smear-negative, culture-positive pulmonary tuberculosis cases (Group A) and 29.73 ± 20.55 nmol/hour/mL in smear-negative, culture-negative sequel pulmonary tuberculosis cases (Group B). Serum chitotriosidase levels from patients in Group A were significantly higher than in Group B and Group C. There was no statistically significant difference in serum chitotriosidase levels between cases with sequel pulmonary tuberculosis (Group B, smear-negative, culture-negative) and healthy controls (Group C). CONCLUSION: In patients with active tuberculosis and a negative sputum smear for acid-fast bacillus, plasma chitotriosidase activity seems to be a strong marker for diagnosis of active disease which can be used while awaiting culture results.

Pulmonary Rehabilitation Using Modified Threshold Inspiratory Muscle Trainer (IMT) in Patients with Tetraplegia.

It is aimed to present the usefulness of inspiratory muscle trainer (IMT) in treatment of a 20-year-old male patient with diaphragmatic paralysis and tetraplegia due to spinal cord injury (SCI), and supporting effect of IMT in recovering from respiratory failure by rendering his diaphragm functions. The treatment was applied through the tracheostomy cannula by a modified IMT device. After applying IMT for three weeks, it was observed that the diaphragm recovered its functions in electromyography (EMG) test. As a result, in this study, we present a case where a patient could live without any respiratory device for the rest of his life with the help of modified IMT.

FDG PET findings in a case with acute pulmonary silicosis.

A 21-year-old male having a history of 4 years of working at a denim factory as a sandblaster was diagnosed with pulmonary silicosis and he was also an active smoker. Productive cough, dyspnea on effort, night sweats, and weight loss in a short period of time were his complaints. Chronic occupational exposure to tiny particles of silicon dioxide can stimulate parenchymal inflammation, collagen synthesis and, ultimately pulmonary fibrosis called silicosis. A typical history of exposure and chest X-ray is usually enough for diagnosis. No effective treatment exists except supportive care. Although chest X-ray of the patient revealed bilateral disseminated micronodular densities, a peripherally diffuse prominent FDG [(F-18)-2-fluoro-2-deoxy-D-glucose] uptake in both lungs and faint FDG uptake in mediastinal lymph nodes demonstrating active inflammation regions were noted on PET (Positron Emission Tomography) scan. This case was presented to show the active disease discriminated by FDG PET from chronic changes detected by radiological studies. FDG PET can provide additional information to CT regarding the diagnosis of acute silicosis and the rare accelerated silicosis.

Association of radiographic emphysema and airflow obstruction with lung cancer.

RATIONALE: To study the relationship between emphysema and/or airflow obstruction and lung cancer in a high-risk population. OBJECTIVE: We studied lung cancer related to radiographic emphysema and spirometric airflow obstruction in tobacco-exposed persons who were screened for lung cancer using chest computed tomography (CT). METHODS: Subjects completed questionnaires, spirometry, and low-dose helical chest CT. CT scans were scored for emphysema based on National Emphysema Treatment Trial criteria. Multiple logistic regressions estimated the independent associations between various factors, including radiographic emphysema and airflow obstruction, and subsequent lung cancer diagnosis. MEASUREMENTS AND MAIN RESULTS: Among 3,638 subjects, 57.5, 18.8, 14.6, and 9.1% had no, trace, mild, and moderate-severe emphysema, and 57.3, 13.6, 22.8, and 6.4% had no, mild (Global Initiative for Chronic Obstructive Lung Disease [GOLD] I), moderate (GOLD II), and severe (GOLD III-IV) airflow obstruction. Of 3,638 subjects, 99 (2.7%) received a lung cancer diagnosis. Adjusting for sex, age, years of cigarette smoking, and number of cigarettes smoked daily, logistic regression showed the expected lung cancer association with the presence of airflow obstruction (GOLD I-IV, odds ratio [OR], 2.09; 95% confidence interval [CI], 1.33-3.27). A second logistic regression showed lung cancer related to emphysema (OR, 3.56; 95% CI, 2.21-5.73). After additional adjustments for GOLD class, emphysema remained a strong and statistically significant factor related to lung cancer (OR, 3.14; 95% CI, 1.91-5.15). CONCLUSIONS: Emphysema on CT scan and airflow obstruction on spirometry are related to lung cancer in a high-risk population. Emphysema is independently related to lung cancer. Both radiographic emphysema and airflow obstruction should be considered when assessing lung cancer risk.

[Diagnosis of venous thromboembolism by single-detector row and multi-detector row CT angiography]. / Venöz tromboembolizm tanisinda tek detektör sirali ve çok detektör sirali BT anjiyografi.

Aim of this study is to determine the diagnostic value of pulmonary angiography performed by either single-detector row CT (SDCT) or multi-detector row CT (MDCT) in patients suspected of venous thromboembolism (VTE). SDCT was performed on 36 and MDCT on 18 of total of 54 patients on whom V/Q scintigraphy was obtained with a suspicion of VTE. Sixteen out of 54 cases got additional pulmonary DSA. Statistical analyses were based on final clinical diagnoses of the individual cases. Twenty-six out of 54 cases in the study got the final diagnoses of VTE and VTE was certainly excluded in the remaining 28. Sixteen out of true 26 VTE cases were in the SDCT group while the other 10 cases took place in the MDCT group, none of which was missed by either technique. There was one false positive result in the SDCT group and none in the MDCT group (96% and 100% specificity respectively, 100% sensitivity for both). Only 9% of all pulmonary emboli detected by SDCT assisted pulmonary angiography were located in subsegmental arterial branches, whereas 24% of emboli detected by MDCT angiography were subsegmental. Both SDCT and MDCT angiography are reliable tests in the detection of VTE. MDCT assisted pulmonary angiography is superior than SDCT assisted pulmonary angiography in subsegmental VTE detection.

The predictive value of serum procalcitonin levels in adult patients with active pulmonary tuberculosis.

The aim of our prospective study was to evaluate the predictive value of serum procalcitonin (PCT) level in comparison with C-reactive protein level and erythrocyte sedimentation rate for the diagnosis of pulmonary tuberculosis (PTB) on admission and 6 months after the administration of anti-tuberculous chemotherapy (ATCT). Seventy-five adult male patients with active PTB who were mycobacteriologically diagnosed (smear and culture positivity) were examined in this study. As a control group, 75 healthy adult males were enrolled. The measured serum PCT levels were within the normal range both in healthy individuals and in patients 6 months after ATCT. Serum PCT levels had been slightly high on admission in patients with PTB in comparison with controls (P = 0.01) and patients who had ATCT (P = 0.001), and this difference was statistically significant, but the PCT levels of most cases with PTB (58.7%) were below the usual cut-off level (0.5 ng/mL). We conclude from this study that the serum PCT level was not a reliable indicator in the diagnosis of active PTB because of its low sensitivity (41.3%), and in most cases it was not capable of overcoming the cut-off level even if statistically meaningful results were obtained. The PCT test for the presumptive diagnosis of PTB cannot be substituted for microbiological, epidemiological, clinical and radiological data.

Bronchial artery embolization: experience with 10 cases.

PURPOSE: To report our experience with 10 cases of bronchial artery embolization (BAE). MATERIALS AND METHODS: The study included 18 cases (11 men and 7 women between 21 and 81 years of age, average 52 years), whose massive hemoptyses could not be controlled with conservative and bronchoscopic methods and were sent to the digital subtraction angiography unit between August 2002 and May 2004. Of these 18 cases, BAE was performed in 10 (7 men and 3 women between 21 and 78 years of age, average 54.2 years). An aortogram with a 5F pigtail catheter and a selective bronchial angiogram with a 4F glide Cobra (C2) catheter was obtained in every case. The same C2 catheters that had been used for bronchial angiography were also used for BAE in 7 cases. Hydrophilic microcatheters were additionally needed for BAE in the other 3 cases. Particles > 250 microns (polyvinyl alcohol [PVA], Embosphere microspheres), mechanical coils, or a combination of both were used for BAE. RESULTS: The etiologies of 10 cases in which BAE was performed were tuberculosis (n=3), sarcoidosis (n=3), bronchiectasis (n=2), and malignancy (n=2). Arterial bronchial pathology was also seen in the non-selective angiographic studies of 4 of the 10 BAE cases. Hemoptysis was controlled in all BAE cases in the first session. Recurrences were observed in 2 cases that were embolized with only mechanical coils during the first month follow-up and hemoptysis was again controlled with microparticle embolization with Embosphere microspheres. All 10 cases were followed- up for 1-21 months (average, 8 months). CONCLUSION: Non-selective angiographic examination alone, is not sufficient enough to detect the vascular pathology causing a massive hemoptysis. A selective study must be performed in every case. The cost of angiography can be lowered by using the same 4F glide C2 catheter for BAE. It may not be safe to use only mechanical coils in BAE cases. There is a need for studying additional cases to have more definitive conclusions.

The effect of oral prednisolone with chronic obstructive pulmonary disease undergoing coronary artery bypass surgery.

BACKGROUND: Chronic obstructive pulmonary disease is still one of the most important problems in patients undergoing cardiopulmonary bypass. The purpose of this prospective study was to assess the beneficial effects of oral prednisolone on pulmonary functions in patients undergoing cardiopulmonary bypass. METHODS: Forty patients with chronic obstructive pulmonary disease were divided into two groups randomly and were given 20 mg oral prednisolone once daily perioperatively (Group I, n = 20) or identical placebo (Group II, n = 20). FEV(1) values, dates of intensive care unit and hospital stays of the two groups were compared. RESULTS: FEV1 values during the admission to our hospital were similar in each group mean predicted FEV1: 56.7 +/- 5.35% in Group I and 57.2 +/- 4.88% in Group II (p = 0.759). After 10 days of oral prednisolone treatment in Group I, predicted FEV1 values were significantly different between two groups (63.2%+/- 4.24 and 57.9%+/- 4.38) (p = 0.0001). While predicted FEV1 values revealed difference between two groups at the date of discharge (p = 0.0001) the values became similar at the third month (55.6%+/- 4.09 in Group I and 55.45%+/- 3.87 in Group II) (p = 0.897). CONCLUSION: Various types of complications may occur after cardiopulmonary bypass. Oral prednisolone not only decreases the rates of complications (reintubation, intubation times, and rhythm disturbances) but also decreases the cost of cardiac operations according to shorter hospital stays.

[The role of high resolution computerized tomography (HRCT) in the diagnosis and treatment of pulmonary tuberculosis]. / Aktif akciger tüberkülozunun tanisinda yüksek rezolüsyonlu bilgisayarli tomografinin yeri.

In this study we have tried to put forth the role of thorax high resolution computerized tomography (HRCT) in the pursue of the diagnosis and treatment of pulmonary tuberculosis. It was detected that of the 67 patients with active tuberculosis, 66 (98.5%) had centrilobular nodule or branching linear structures, 65 (97%) had acinary nodule, 55 (82%) had consolidation, 55 (82%) had cavities, 54 (80.5%) had tree in bud appearance and 52 (77.6%) were bilateral. Of 30 patients suffering from inactive tuberculosis, 26 (86.6%) were detected to have fibrotic changes, 20 (66.6%) bronchiectasis, 18 (60%) bronchovascular distortion and 14 (46.6%) pericicatrial emphysema. The sensitivity, specificity, positive predictive value, negative predictive values of thorax HRCT in determining the activity of the illness were found as 97%, 86.7%, 94.2% and 92.9% respectively. In conclusion we can say that thorax HRCT is a powerful and reliable diagnostic method for pulmonary tuberculosis. Thorax HRCT can be used as noninvasive diagnostic method especially in the patients suffering from smear and culture negative active tuberculosis.

Effect of dose-rate and lung dose in total body irradiation on interstitial pneumonitis after bone marrow transplantation.

The aim of this study is to evaluate the incidence of interstitial pneumonitis following fractionated total body irradiation conditioning for bone marrow transplantation with varying lung doses due to shielding technique and different dose-rates. Between 1987 and 2001, a total number of 105 patients have received total body irradiation conditioning for bone marrow transplantation for hematological malignancies at Gulhane Military Medical School. Twelve Gy fractionated total body irradiation was delivered in 6 fractions over 3 consecutive days with Co-60 teletherapy machine. Conditioning therapy included only cyclophosphamide (60 mg/ kg/day for two days) and total body irradiation. The median follow-up for patients was 12 months. Interstitial pneumonitis developed in 10 patients out of 105 patients (9.52%). The median total dose to lung was 9.60 Gy (8.88-10.90). The difference between total lung dose and interstitial pneumonitis was not significant. Pneumonitis development in the high dose-rate (>0.04 Gy/min) group versus low dose-rate (< or =0.04 Gy/min) group was statistically significant. Low dose-rate fractionated total body irradiation is a reliable conditioning program in bone marrow transplantation with effective lung sparing to avoid interstitial pneumonitis.

[The value of fiberoptic bronchoscopy in diagnosis of smear negative pulmonary tuberculosis]. / Yayma negatif akciger tüberkülozu tanisinda fiberoptik bronkoskopinin degeri.

Although mycobacterial culture positivity is the gold standard for the diagnosis, the initial approach to the diagnosis of pulmonary tuberculosis (PTbc) is the detection of acid-fast bacilli (AFB) in respiratory specimens as recommended by the World Health Organization. But the physicians have to make a decision for the patients whose sputum smears are negative or who can not produce sputum. Waiting for culture results with radiological follow up or empirical antituberculous therapy are the standard options. In our study we aimed to assess the diagnostic yield of fiberoptic bronchoscopy in patients, suspected to have tuberculosis, whose sputum smears were negative or who could not produce sputum. Fifty six patients who suspected to have PTbc with sputum smear negative were enrolled in the study (fiberoptic bronchoscopy and selective bronchial washings were done to all patients. Bronchial washings were obtained from the affected parts). Mucosal biopsies were done in patients in where endobronchial abnormalities were noted. Transbronchial biopsies were done in selected patients from the radiological localizations. Ziehl-Nielsen staining and culture in Löwenstein-Jensen medium were the microbiological studies. Typical granulomas were expected to detect on histopathologic examination. Bronchoscopic lavage smears were positive for Mycobacterium tuberculosis in 13 (23%) patients. Twenty eight (50%) patients had positive culture. Histopathological results confirmed tuberculosis in eight of 20 patients who had undergone mucosal biopsies, four of seven of transbronchial biopsies, two of three of needle aspiration biopsies. By bronchoscopic procedures early diagnosis was performed in 27 (48.21%) patients. We concluded that fiberoptic bronchoscopy has an important role in the diagnosis of patients suspected to have tuberculosis, whose sputum smears were negative or who could not produce sputum. It is useful and necessary in selected cases.

[Pulmonary function and nutrition]. / Solunum fonksiyonlari ve beslenme.

Respiratory system disease itself can cause malnutrition, while nutritional status can be the cause of or enhance respiratory failure. Malnutrition which exists 27-71 percent in chronic obstructive pulmonary disease, is a factor that determines functional capacity and mortality.

[Diagnostic value of postbronchoscopic sputum, bronchoscopic lavage, and transbronchial biopsy in peripheral lung cancer]. / Periferik akciger kanserlerinin tanisinda bronkoskopik lavaj, brons biyopsi ve postbronkoskopik balgam sitolojisinin tani degeri.

The aim of this prospective study was to review the value of bronchoscopic lavage, transbronchial biopsy and postbronchoscopic sputum cytology in peripheral lung cancer. Two groups of patients were involved in the study who were treated in our clinic between the years 1999 and 2001: Group I (22 patients; average age 64 +/- 9 years; 18 males and four females) whose lesions were peripherally localised on chest radiographs and Group II (28 patients; average age 61 +/- 8; 26 males and two females) whose lesions were centrally localised and were visible only by diagnostic bronchoscopic procedures. The following procedures and analysis were done in all patients: Cytologic analysis of prebroncoscopic sputum, bronchoscopic lavage, bronchial biopsy, and patients were asked to give sputum in 30 minutes after bronchoscopy. The final diagnosis of all patients was primary lung cancer. In the first group none of the patients had visible endobronchial lesion on fiberoptic bronchoscopy. Sputum cytology of the patients were negative before bronchoscopy. Bronchoscopic lavage cytology was positive in five of 22 patients (22.7%). Transbronchial biopsy provided better diagnostic yield (50%) than postbronchoscopic sputum (31.8%). In the second group of patients, cytologic analysis was positive 25%, 96.4% and 42.9% in bronchoscopic lavage, bronchial biopsy and postbronchoscopic sputum respectively. Our findings suggest that postbronchoscopic sputum cytology may be an important diagnostic procedure in endoscopically nonvisible pulmonary cancer. Since its application is easy and noninvasive, cytologic analysis of postbronchoscopic sputum may be preferable to bronchoscopic biopsy although a favorable diagnostic yield is not expected.