Adding Non-Invasive Positive Pressure Ventilation to Supplemental Oxygen During Exercise Training in Severe Chronic Obstructive Pulmonary Disease: A Randomized Controlled Study.

OBJECTIVE: Chronic obstructive pulmonary disease is currently the fourth leading cause of death in the world. Pulmonary rehabilitation is recommended for chronic obstructive pulmonary disease. MATERIAL AND METHODS: This study aimed to evaluate the effects of non-invasive ventilation, supplemental oxygen, and exercise training and supplemental oxygen during exercise training during pulmonary rehabilitation practice in comparison with only exercise training on lung functions, blood gases, lactate levels, respiratory muscle pressures, dyspnea, walking distances, quality of life, and depression in patients with severe chronic obstructive pulmonary disease. The main outcome measure is exercise capacity (6-minute walk test), and the secondary end-point included quality of life. RESULTS: Thirty-five patients (mean ± SD age, 65.4 ± 6.5 years) with a mean bronchodilator forced expiratory volume in the first second of expiration of 39.4 ± 7%, undergoing an 8-week outpatient pulmonary rehabilitation, were randomized to either non-invasive ventilation, supplemental oxygen, and exercise training, supplemental oxygen during exercise training, or exercise training groups. The improvements in respiratory muscle strength were higher in non-invasive ventilation, supplemental oxygen, and exercise training patients than the moderate improvements in the exercise training group. Both non-invasive ventilation, supplemental oxygen, and exercise training and supplemental oxygen during exercise training groups showed significant increases in the 6-minute walk test and incremental shuttle walk test. However, the increase in walking distance was better in non-invasive ventilation, supplemental oxygen, and exercise training group (69.8 ± 53.2 m in 6-minute walk test and 66.6 ± 65.2 m in incremental shuttle walk test, P = .001 and P = .005, respectively) compared to supplemental oxygen during exercise training group (42.5+55.5 m in 6-minute walk test and 53.5+70.2 m in incremental shuttle walk test, P = .01 each, respectively). The total St. George's Respiratory Questionnaire score was similar in all study groups after the intervention. Symptoms of depression significantly improved only in non-invasive ventilation, supplemental oxygen, and exercise training group (-2.8+2.8, P = .006). CONCLUSION: Non-invasive positive-pressure ventilation (NIPPV) added to supplemental oxygen during exercise training was associated with better physiological adaptations than other modalities.

The evaluation of disease awareness, caregiver burden, and workday loss in caregivers of COPD patients.

BACKGROUND: Our aim is to determine the caregiver burden of chronic obstructive lung disease (COPD) patient's caregivers, and to determine whether there is a workday loss. METHODS: 252 COPD patients and their caregivers were included. Disease information of the patients were recorded and a questionnaire was applied. Socio-demographic characteristics of the caregivers were recorded and a questionnaire consisting of 24 questions including COPD disease, treatment and loss of working days, and the Zarit Scale were used. RESULTS: 128(50.8%) of the patients according to GOLD were group-D, 97(38.5%) of the patient's relatives were working, 62(24.7%) were not able to go to work for 1-14 days, and 125(57.1%) spent outside the home from 1-14 nights, because those accompanied to patients. In univariate analysis were detected modified medical research council (mMRC) (p < 0.001), CAT (p < 0.001), the number of comorbidities of patients (p = 0.027), forced expiratory volume in 1 FEV1cc (p = 0.009), FEV1% (p < 0.001), the presence of long term oxygen therapy (LTOT), and the number of comorbidities of the patient's relatives (p = 0.06) increased the care load. In multiple linear regression analysis, age (p = 0.03), COPD assessment test (CAT) score (p = 0.001), FEV1% (<0.068) and the number of comorbidities of patients (p = 0.01) and the number of comorbidities of caregivers (p = 0.003) increased the caregiving burden. DISCUSSION: In COPD increases caregiving burden. This burden is greater in symptomatic patients and when comorbidities are present. Psychosocial and legal regulations should be investigated and solutions should be produced for the caregivers of COPD patients.

The CO-MIND Study: Chronic Obstructive Pulmonary Disease Management in Daily Practice and Its Implications for Improved Outcomes According to GOLD 2019 Perspective.

Purpose: GOLD 2019 proposed a novel treatment decision tool for follow-up based on the predominant trait (exacerbation or dyspnea) of patients, alongside treatment escalation and de-escalation strategies. This study was designed to provide an up-to-date snapshot of patient and disease characteristics, treatment pathways, and healthcare resource use (HRU) in COPD in real life, and comprehensively examine patients considering GOLD 2019 recommendations. Patients and Methods: This mixed design, observational, multicenter (14 pulmonology clinics) study included all patients with a documented COPD diagnosis (excluding asthma-COPD overlap [ACO]) for ≥12 months, aged ≥40 years at diagnosis who had a COPD-related hospital visit, spirometry test and blood eosinophil count (BEC) measurement under stable conditions within the 12 months before enrollment between February and December 2020. Data were collected cross-sectionally from patients and retrospectively from hospital medical records. Results: This study included 522 patients (GOLD group A: 17.2%, B: 46.4%, C: 3.3%, D: 33.1%), of whom 79.5% were highly symptomatic and 36.2% had high risk of exacerbation. Exacerbations (n = 832; 46.6% moderate, 25.5% severe) were experienced by 57.5% of patients in the previous 12 months. Inter-rater agreement between investigators and patients regarding the reason for visit was low (κ coefficient: 0.338, p = 0.001). Inhaled treatment was modified in 88 patients at index, mainly due to symptomatic state (31.8%) and exacerbations (27.3%); treatment was escalated (57.9%, mainly switched to LABA+LAMA+ICS), inhaler device and/or active ingredient was changed (36.4%) or treatment was de-escalated (5.7%). 27% had ≥1 hospital overnight stay over 12 months. Emergency department visits and days with limitation of daily activities were higher in group D (p < 0.001). Conclusion: Despite being on-treatment, many patients with COPD experience persistent symptoms and exacerbations requiring hospital-related HRU. A treatable trait approach and holistic disease management may improve outcomes by deciding the right treatment for the right patient at the right time.

2021 Guideline for the Management of COPD Exacerbations: Emergency Medicine Association of Turkey (EMAT) / Turkish Thoracic Society (TTS) Clinical Practice Guideline Task Force.

Chronic obstructive pulmonary disease (COPD) is an important public health problem that manifests with exacerbations and causes serious mortality and morbidity in both developed and developing countries. COPD exacerbations usually present to emergency departments, where these patients are diagnosed and treated. Therefore, the Emergency Medicine Association of Turkey and the Turkish Thoracic Society jointly wanted to implement a guideline that evaluates the management of COPD exacerbations according to the current literature and provides evidence-based recommendations. In the management of COPD exacerbations, we aim to support the decision-making process of clinicians dealing with these patients in the emergency setting.

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 Cross-Sectional Study in Patients with Severe COPD to Assess the Perception of Symptom Variability (COPVAR) in the Middle East and Africa.

Purpose: This study was performed to assess symptom variability and its impact on morning activities in stable patients with severe COPD in the Middle East and Africa (MEA) countries. Patients and methods: Non-interventional, cross-sectional study (NCT03425760) in patients with severe COPD (GOLD 2015, C, or D categories). Symptom variability was assessed directly by interviewing the patient and using the Global Chest Symptoms Questionnaire (GCSQ). The impact on morning activities was assessed using the Capacity of Daily Living during the Morning (CDLM) and the Morning Activities and Symptoms Questionnaire (MASQ). Results: A total of 3253 patients (mean±SD age: 64.1±9.5 years, 90.3% males) were enrolled. Overall, 81.6% and 83.4% of patients reported weekly and daily symptom variability, respectively. The number of exacerbations in the previous year, smoking cessation, and COPD GOLD D were the most consistent factors associated with symptom variability. The GCSQ score was significantly higher (p<0.001) in GOLD D than in GOLD C patients at each time during the day. In GOLD D, the mean (±SD) GCSQ score was higher at night (1.6±1.2, p<0.001) and in the morning (1.5±1.0, p<0.001) than in the afternoon (1.3±0.9), suggesting daytime variability of breathlessness and chest tightness. Overall, 60.0% of GOLD D patients (versus 13.6% GOLD C, p<0.0001) had difficulty getting out of bed due to COPD. Patients with symptom variability had significantly more difficulty to get out of bed, especially patients with chest tightness variability (p<0.0001) and wheezing variability (p<0.0001). The CDLM global score was significantly lower (p<0.0001) in GOLD D than in GOLD C patients (3.5±1.1 and 4.6 ± 3.5, respectively). Daily variability in chest tightness and wheezing was also significantly associated with CDLM scores (p<0.0001). Conclusion: In MEA countries, patients with severe stable COPD reported significant daily and weekly symptom variability which affects morning activities, particularly in GOLD D patients.

Efficacy and safety of the direct switch to indacaterol/glycopyrronium from salmeterol/fluticasone in non-frequently exacerbating COPD patients: The FLASH randomized controlled trial.

BACKGROUND AND OBJECTIVE: Combination long-acting ß2 -agonist/long-acting muscarinic antagonist (LABA/LAMA) has demonstrated superior clinical outcomes over LABA/inhaled corticosteroid (ICS) in chronic obstructive pulmonary disease (COPD) patients; however, data from blinded randomized controlled trials on direct switching from LABA/ICS to LABA/LAMA are lacking. FLASH (Assessment of switching salmeterol/Fluticasone to indacateroL/glycopyrronium in A Symptomatic COPD patient coHort) investigated if direct switch, without a washout period, from salmeterol/fluticasone (SFC) to indacaterol/glycopyrronium (IND/GLY) in COPD patients improves lung function and is well tolerated. METHODS: In this 12-week, multicentre, double-blind study, patients with moderate-to-severe COPD and up to one exacerbation in previous year, receiving SFC for ≥3 months, were randomized to continue SFC 50/500 µg twice daily (bd) or switch to IND/GLY 110/50 µg once daily (od). Primary endpoint was pre-dose trough forced expiratory volume in 1 s (FEV1 ) at Week 12. RESULTS: In total, 502 patients were randomized (1:1) to IND/GLY or SFC. Patients switched to IND/GLY demonstrated superior lung function (pre-dose trough FEV1 ) versus SFC at Week 12 (treatment difference (Δ) = 45 mL; P = 0.028). IND/GLY provided significant improvements in pre-dose trough forced vital capacity (FVC; Δ = 102 mL; P = 0.002) and numerical improvements in transition dyspnoea index (TDI; Δ = 0.46; P = 0.063). Rescue medication use and COPD assessment test (CAT) scores were comparable between groups. Both treatments had similar safety profiles. CONCLUSION: FLASH demonstrated that a direct switch to IND/GLY from SFC improved pre-dose FEV1 and FVC in COPD patients with up to one exacerbation in the previous year. No new safety signals were identified.

Effects of pulmonary rehabilitation in patients with mild-to-moderate chronic obstructive pulmonary disease: Bottom of an iceberg.

OBJECTIVES: This study aims to compare the effects of pulmonary rehabilitation (PR) in patients with mild-to-moderate and severe-to-very severe chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: Between January 2005 and December 2010, a total of 76 patients with mild-to-moderate (Global Initiative for Chronic Obstructive Lung Disease [GOLD] Stages I+II, n=33, mean age 66.0±8.6 years) and severe-to-very severe (GOLD Stages III+IV, n=43, mean age 63.5±8.8 years) COPD completed an eight-week outpatient PR program. Incremental and endurance shuttle walk tests (ISWT, ESWT), St. George's Respiratory Questionnaire (SGRQ), Chronic Respiratory Questionnaire (CRQ), and Hospital Anxiety and Depression Scale were assessed before and after PR. Changes after the intervention were compared between two groups. RESULTS: There were significant improvements in the ISWT and median 60 m [(-150)-(400)] in mild-to-moderate group and 70 m [(0)-(270)] in severe-to-very severe group (both, p<0.001). The ESWT time improved in both groups, 122s [(-279)-(665)] (p=0.002) and 61s [(-180)- (878)] (p<0.001), respectively. Significant effects were observed in all domains of the SGRQ except the impact score in mild-to-moderate patients. There were significant improvements in all domains except the symptoms score in severe-to-very severe patients. Using the CRQ, a significant improvement was shown in all domains of CRQ except the dyspnea score of mild-to-moderate patients. Anxiety and depression scores decreased after PR in both groups (p<0.05). According to changes in outcomes, there was no difference in any parameters between two groups. CONCLUSION: This study demonstrates that patients with mild-to-moderate COPD benefit from PR comparably to patients with severe-to- very-severe COPD. Although patients with mild-to-moderate COPD are not usually symptomatic, our findings suggest that they should be included in PR.

The View of the Turkish Thoracic Society on the Report of the GOLD 2017 Global Strategy for the Diagnosis, Management, and Prevention of COPD.

Since the Global Initiative for Obstructive Lung Disease (GOLD) published its first guidelines on chronic obstructive pulmonary disease (COPD) in 2001, much has changed till 2017. Previous versions of GOLD guidelines mentioned the forced expiratory volume in one second (FEV1)-based approach for staging and treatment modalities. Since 2011, a composite multi-dimensional approach has been introduced to cover various aspects of the disease. Unfortunately, this approach was not found to be correlated with mortality as well as the FEV1-based approach, despite the fact that it was better for estimating exacerbation rates. Although this assessment tool has been considered as a big step in personalized medicine, the system was rather complex to use in daily practice. In 2017, GOLD introduced a major revision in many aspects of the disease. This mainly includes a revised assessment tool and treatment algorithm. This new ABCD algorithm has excluded spirometry for guiding pharmacological therapy. Treatment recommendations are mainly based on symptoms and exacerbation rates. Escalation and de-escalation strategies have been proposed for the first time. The spirometric measurement has only been retained to confirm the diagnosis and lead to nonpharmacological therapies. In this report, the Turkish Thoracic Society COPD assembly aimed to summarize and give an insight to the Turkish interpretation of GOLD 2017.

Can fiberoptic bronchoscopy be applied to critically ill patients treated with noninvasive ventilation for acute respiratory distress syndrome? Prospective observational study.

BACKGROUND: Noninvasive ventilation (NIV) is a cornerstone for the treatment of acute respiratory failure of various etiologies. Using NIV is discussed in mild-to-moderate acute respiratory distress syndrome (ARDS) patients (PaO2/FiO2 > 150). These patients often have comorbidities that increase the risk for bronchoscopy related complications. The primary outcome of this prospective observational study was to evaluate the feasibility, safety and contribution in diagnosis and/or modification of the ongoing treatment of fiberoptic bronchoscopy (FOB) in patients with ARDS treated with NIV. METHODS: ARDS patients treated with NIV and who require FOB as the diagnostic or therapeutic procedure were included the study. Intensive care ventilators or other dedicated NIV ventilators were used. NIV was applied via simple oro-nasal mask or full-face mask. Pressure support or inspiratory positive airway pressure (IPAP), external positive end expiratory pressure (PEEP) or expiratory positive airway pressure (EPAP) levels were titrated to achieve an expiratory tidal volume of 8 to 10 ml/kg according to ideal body weight, SpO2 > 90 % and respiratory rate below 25/min. RESULTS: Twenty eight subjects (mean age 63.3 ± 15.9 years, 15 men, 13 women, PaO2/FiO2 rate 145 ± 50.1 at admission) were included the study. Overall the procedure was well tolerated with only 5 (17.9 %) patients showing minor complications. There was no impairment in arterial blood gas and cardiopulmonary parameters after FOB. PaO2/FiO2 rate increased from 132.2 ± 49.8 to 172.9 ± 63.2 (p = 0.001). No patient was intubated within 2 h after the bronchoscopy. 10.7, 32.1 and 39.3 % of the patients required invasive mechanical ventilation after 8 h, 24 h and 48 h, respectively. Bronchoscopy provided diagnosis in 27 (96.4 %) patients. Appropriate treatment was decided according to the results of the bronchoscopic sampling in 20 (71.4 %) patients. CONCLUSION: FOB under NIV could be considered as a feasible tool for diagnosis and guide for treatment of patients with ARDS treated via NIV in intensive care units. However, FOB-correlated life-treathening complications in severe hypoxemia should not be forgotten. Furthermore, further controlled studies involving a larger series of homogeneous ARDS patients undergoing FOB under NIV are needed to confirm these preliminary findings.

Categorization of COPD patients in Turkey via GOLD 2013 strategy document: ALPHABET study.

OBJECTIVE: To determine distribution of COPD assessment categories and physicians' adherence to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013 strategy in Turkish COPD patients. METHODS: A total of 1,610 COPD patients (mean [standard deviation] age: 62.6 [9.9] years, 85.7% were males) were included in this multicenter, non-interventional, cross-sectional study. Patients were categorized via GOLD 2013 strategy document. Consistency between reported and re-classified GOLD categories, and measures used for symptom evaluation and exacerbation was analyzed. RESULTS: Overall, 41.1% of patients were assigned to GOLD A, while 13.2% were assigned to GOLD C categories. Long-acting beta-2 agonist + long-acting muscarinic antagonist + inhaled corticosteroid regimen was the most common treatment (62.0%). Over-treatment was noted in >70% of GOLD A, B, and C patients. A high consistency between measures of symptom evaluation (Kappa coefficient =0.993, P<0.0001) and a low-moderate consistency between exacerbation risk measures (Kappa coefficient =0.237, P<0.0001) were noted. CONCLUSION: Our findings revealed GOLD A as the most prevalent category in Turkish cohort of COPD patients. Group assignment was altered depending on the chosen measure for symptom and risk assessment. Physician non-adherence to treatment recommendations in GOLD 2013 document leading to over-treatment in patients assigned to GOLD A, B, and C categories was also detected.

Multidisciplinary clinical management of paroxysmal nocturnal hemoglobinuria.

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare, acquired disease caused by clonal expansion of one or more hematopoietic stem cell (HSC) lines due to a somatic mutation of the phosphatidylinositol glycan anchor (PIG-A) gene located on Xp22.1. PNH incidence is 1.5-2 cases per million of the population per year. PNH can affect multiple systems in the body and requires multidisciplinary clinical management. Patients can manifest with severe pancytopenia, life-threatening thrombosis affecting the hepatic, abdominal, cerebral, and subdermal veins, and high requirements for blood transfusion due to haemolytic anemia. PNH can also be associated with bone marrow failure. Advances in diagnostic techniques and a targeted therapeutic approach for PNH have emerged in the last two decades. Eculizumab, a promising humanized monoclonal antibody against C5, is the first approved therapy for PNH.

Updates in Chronic Obstructive Pulmonary Disease for the Year 2014.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in the world. Research conducted over the past decade has contributed much to our current knowledge of the pathogenesis and treatment of COPD. Additionally, an evolving literature has recently accumulated information about the management of COPD and also about exacerbations. This article reviews a concise summary on the updates in COPD including 1) new pathogenic mechanisms and therapeutic targets, 2) management of patients in Group B, C and D according to GOLD 2014 report; 3) prevention and management of exacerbation; 4) monitoring of natural history; and 5) essential but usually forgotten parts of the management.

Effects of nutritional supplementation combined with conventional pulmonary rehabilitation in muscle-wasted chronic obstructive pulmonary disease: a prospective, randomized and controlled study.

BACKGROUND AND OBJECTIVE: Nutritional depletion in chronic obstructive pulmonary disease (COPD) adversely affects health status and mortality. We aimed to evaluate the effects of nutritional supplementation (NS) with pulmonary rehabilitation (PR) on body composition, mid-thigh cross-sectional area (CSA), dyspnoea, exercise capacity, health-related quality of life, anxiety and depression in advanced COPD patients. METHODS: Forty-six patients were randomized to PR and nutritional support (PRNS), PR or the control group. Dyspnoea was measured with Medical Research Council and BORG scales. Exercise capacity was measured through 6-min walk test and shuttle tests; health-related quality of life was assessed with St. George's Respiratory Questionnaire. Psychological status was measured with Hospital Anxiety and Depression Scale. Body weight and body mass indexes (BMI) were also evaluated. Fat-free mass was measured through bioelectrical impedance analyser. The CSA of quadriceps was calculated in mid-level of the thigh with magnetic resonance imaging. RESULTS: Dyspnoea and total scores of St. George's Respiratory Questionnaire improved in both groups (P < 0.05). Six-minute walk test and incremental shuttle walk test distances in PRNS and PR patients increased significantly as (62.6 ± 42.4 m, 43.3 ± 59.2 m, both P = 0.001; and 63.3 ± 70.1 m and 69.3 ± 69.7 m, both P = 0.001). Although anxiety improved in both groups (P < 0.05), there was no change in depression. Body weight, BMI and fat-free mass index (FFMI) (1.1 ± 0.9 kg, 0.2 ± 1.4 kg/m(2) and 0.6 ± 0.5 kg/m(2), P < 0.05) in PRNS, whereas body weight and FFMI (0.6 ± 0.7 kg, 0.1 ± 0.6 kg/m(2) P < 0.05) increased in PR after the intervention. There was a significant increase in mid-thigh CSA (2.5 ± 4.1 cm(2)) only in PRNS (P = 0.04). CONCLUSION: The combination of NS with PR resulted in improvements particularly in lean body mass and mid-thigh CSA. This study suggests combining NS with PR in reversing weight loss and muscle wasting in COPD.

[The role of endotracheal aspiration in the diagnosis of ventilator associated pneumonia]. / Ventilatörle iliskili pnömoni tanisinda endotrakeal aspiratin degeri.

INTRODUCTION: Ventilator associated pneumonia (VAP) is one of the most important causes of mortality in patients treated with invasive mechanical ventilation (IMV) in intensive care unit (ICU). Microbiological examinations are required as clinical and radiological findings are usually insufficient in the diagnosis. MATERIALS AND METHODS: Twenty four patients who were receiving IMV because of respiratory failure, had a Clinical Pulmonary Infection Score (CPIS) of ≥ 6 in the follow-up and died with the suspicion of VAP were enrolled in our study. Six patients were excluded as post-mortem biopsy could not be performed. The patients who had pre-mortem CPIS ≥ 6, in whom a causative organism was identified from the culture of post-mortem lung biopsy and/or histopathological examination of lung biopsy was compatible with pneumonia were diagnosed as VAP. In the 18 patients in whom a post-mortem lung biopsy was performed, quantitative culture results of endotracheal aspirate performed 48 hours prior to death were compared with microbiological and histopathological results of post-mortem lung biopsy specimens, and the role of endotracheal aspirate in the diagnosis of VAP was evaluated retrospectively. RESULTS: Out of 18 patients (12 men, mean age 67.0 ± 13.0 years) included in the study, 11 (61.1%) were diagnosed as VAP. The quantitative culture of endotracheal aspirate was positive in 9 (81.8%) out of 11 patients diagnosed as VAP. The sensitivity, specificity, positive and negative predictive values of endotracheal aspirate culture for identifying VAP were found to be 81.8%, 14.3%, 60.0% and 33.3%, respectively. CONCLUSION: Our study shown that quantitative culture of endotracheal aspirate is a practical and reliable method that can be used for the diagnosis of VAP in patients receiving IMV in ICU and having CPIS ≥ 6.

Hypereosinophilic syndrome presenting with large left ventricular apical thrombus and pulmonary embolism.

A 45-year-old man presented with dyspnea on exertion, fatigue, and cough. Transthoracic echocardiography showed a large apical thrombus in the left ventricle. The laboratory results showed prominent eosinophilia on blood smear, elevated acute phase reactants and D-dimer serum levels. Bone marrow examination showed a Fip1-like platelet-derived growth factor receptor alfa fusion gene mutation. The case was diagnosed as myeloproliferative variant hypereosinophilic syndrome. Contrast-enhanced computed tomography demonstrated thrombi not only in left ventricle but also in multiple segmental pulmonary arteries. Cardiac magnetic resonance imaging showed left ventricular apical thrombus without subendocardial fibrosis. Cardiopulmonary manifestations of hypereosinophilic syndrome completely resolved after treatment.

Comparison of bronchoalveolar lavage and mini-bronchoalveolar lavage in the diagnosis of pneumonia in immunocompromised patients.

BACKGROUND: Pneumonia is a major cause of morbidity and mortality in immunocompromised patients. Bronchoalveolar lavage (BAL) is commonly used to help diagnose and characterize pneumonia in these patients. Mini-BAL is a less-invasive, less-costly and less-cumbersome diagnostic tool than BAL. OBJECTIVES: In this study, we compared the diagnostic value of BAL and mini-BAL in the evaluation of pneumonia in immunocompromised patients with respiratory failure. METHODS: Sixty-four respiratory samples were collected from 32 immunocompromised patients admitted to our respiratory intensive care unit with a clinical diagnosis of pneumonia and respiratory failure requiring invasive mechanical ventilation. A single BAL sample and a single mini-BAL sample were collected from each patient. Samples were examined for bacteriologic, mycologic, mycobacteriologic, and viral organisms. RESULTS: The mean age of the patients was 56.0 ± 14.4 years. Of the 32 BAL samples, bacterial isolates were detected in 11 patients (34.4%) and on the other hand bacterial isolates were detected in 10 patients (31.3%) of the mini-BAL samples. Fungal isolates were detected in 11 patients (34.4%) from BAL samples and 13 patients (40.6%) from mini-BAL samples. Our analysis demonstrated a strong positive correlation between the results of BAL and mini-BAL testing (r = 0.850 and r = 0.821, respectively). CONCLUSION: In this study, we demonstrated a strong correlation between the isolation rates of bacteria and fungi in BAL and mini-BAL samples obtained from immunocompromised patients with pneumonia and respiratory failure. The data strongly support the use of mini-BAL sampling in such patients as a less-invasive, less-costly and simpler alternative to traditional BAL.

[The comparison of patients with hospitalized health-care-associated pneumonia to community-acquired pneumonia]. / Saglik bakimi ile iliskili pnömoni ve toplumkökenli pnömoni tanilari ilehastanede yatan olgularin karsilastirilmasi.

Health-care-associated pneumonia (HCAP) is defined as pneumonia that develops in patients with a history of recent hospitalization, hemodialysis as an outpatient, residence in a nursing home, outpatient intravenous therapy and home wound care. We aimed to compare the initial demographic characteristics, causative agents and prognosis between hospitalized HCAP and community-acquired pneumonia (CAP) patients. HCAP and CAP patients hospitalized between 01 September 2008-01 September 2009 were evaluated retrospectively. Out of 187 patients (131 males, mean age 66.3 ± 14.3 years) who were hospitalized during one-year period, 98 were diagnosed as HCAP and 89 as CAP. Among HCAP patients, 64 (65.3%) had a history of hospitalization in the last 90 days, 26 (26.5%) received outpatient intravenous therapy, 17 (17.3%) had home wound care, 6 (6.1%) were on hemodialysis program in the last 30 days and 4 (4.1%) lived in a nursing home. The causative pathogen was detected in 39 (39.8%) HCAP and 8 (9.0%) CAP patients. The most frequently isolated microorganisms were Pseudomonas aeruginosa and Acinetobacter baumannii in HCAP, and Streptococcus pneumoniae and Haemophilus influenzae in CAP patients. Inappropriate empiric antibiotic treatment was documented in 8 (25.8%) of 39 HCAP patients, in whom a causative agent was isolated whereas the antibiotic treatment was appropriate in all CAP patients. The duration of hospitalization (14.4 ± 11.4 vs. 10.7 ± 7.9 days, p= 0.011) and mortality rate (34.7% vs. 9.0%, p< 0.001) were higher in HCAP compared with CAP patients. As HCAP is different than CAP in terms of patients' characteristics, causative microorganisms and prognosis, it should be considered in all patients hospitalized as CAP. Potentially drug-resistant microorganisms should be taken into consideration in the empirical antibiotic treatment of these patients.

[Comparison of the patients with pandemic (H1N1) influenza A virus pneumonia and community-acquired pneumonia]. / Pandemik (H1N1) influenza A virüsü pnömonisi ve toplum kökenli pnömoni olgularinin karsilastirilmasi.

Prognosis of pandemic influenza A (H1N1) virus pneumonia is worse than community-acquired pneumonia (CAP), therefore it is important to know distinctive clinical features of both pneumonias. The aims of this study were to compare clinical features and prognosis of patients with pandemic influenza A (H1N1) pneumonia and CAP due to other agents. Demographic features, symptoms and findings of 20 pandemic influenza A (H1N1) pneumonia and 18 CAP patients hospitalized between October 1st and December 30th, 2009 were evaluated. One patient (5.0%) with pandemic Influenza A (H1N1) pneumonia and 55.6% of CAP patients were over 65 years (p= 0.001). Symptoms of fever, dyspnea, fatigue, muscle and joint pain, nausea, vomiting and headache were more frequent (p< 0.05), platelet count (p= 0.024) and PaO(2)/FiO(2) ratio (p= 0.006) were lower, number of thrombocytopenic patients (p= 0.024) and LDH levels (p= 0.016) were higher, duration of hospitalization was longer (p= 0.038) in patients with pandemic influenza A (H1N1) pneumonia. There was no difference in terms of radiological findings between two groups. None of the CAP patients were followed-up in the intensive care, whereas five pandemic influenza A (H1N1) pneumonia patients (25.0%) required intensive care and three of them died despite invasive mechanical ventilation. In conclusion, in the presence of fever, dyspnea with non-pulmonary symptoms and accompanying radiological alveolar opacities should be considered as pandemic influenza A (H1N1) pneumonia should be suspected in patients admitted with findings of pneumonia during influenza season. Admission to the intensive care unit and mechanical ventilation should be considered in patients with dyspnea and diffuse radiological findings.

[Tuberculin skin test reactivity in patients with chronic renal failure]. / Kronik böbrek yetmezligi olan olgularda tüberkülin cilt testi yaniti.

The aim of this study was to evaluate the response of tuberculin skin test (TST) and the parameters that affect the response in patients with chronic renal failure (CRF) on different treatment regimens. The study population consisted of 150 patients (78 females, mean age 48.1 + or - 16.7 years, the mean disease duration 6.6 + or - 6.1 years). Of these patients, 50 were on haemodialysis (HD), 50 were renal transplant patients, 26 were on peritoneal dialysis (PD) and 24 were treated medically. TST was performed to all patients, an induration with a diameter of 10 mm or more was accepted as positive response in HD, PD, medical treatment groups, whereas 5 mm or more was considered as positive in transplant group. TST was positive in 52% of the study population (56% in HD group, 54% in PD group, 44% in transplant group, 58% in medical treatment group, p> 0.05). There was a positive correlation between TST and age in patients older than 60 of transplant and medical treatment groups (p= 0.008). In HD patients with negative TST, the number of female patients was higher (p= 0.02). In transplant patients with positive TST, duration of HD was shorter (p= 0.01), the blood urea level was lower (p= 0.04), hemoglobin level was higher (p= 0.04). The ratio of negative TST was higher (p< 0.05), TST reactivity was smaller (p= 0.01) in only transplant patients with no BCG scar. The number of BCG scar was correlated positively with TST (p= 0.04). In the medical treatment group, patients with positive TST response were older (p= 0.02) and in PD group the tuberculin reactivity was not affected by any of the patient-related parameters. It must be considered that the response to TST is low in young patients with uncontrolled CRF and under immunosuppressive therapy.