A new perspective on OSAS cases with the Baveno classification.

OBJECTIVE/BACKGROUND: Since the apnea-hypopnea index (AHI), which is used in the diagnosis and grading of OSAS, does not adequately reflect the clinical perspective of the disease, the Baveno classification of OSA was developed, which allows multicomponent evaluation of OSAS patients. The aim of our study was to evaluate the application of the Baveno classification in clinical practice. PATIENTS/METHODS: A prospective study was performed on patients diagnosed with OSAS between January 2021 and June 2022. Patients were divided into 4 groups according to Baveno classification (Groups A-D) and three groups as mild, moderate, and severe OSAS according to AHI. RESULTS: A total of 378 patients (70% male, mean age 48.68 ± 11.81 years) were included in the study. The patients had mild (n: 75; 20%), moderate (n: 88; 23%), and severe (n: 215; 57%) OSAS. According to Baveno classification, patients were included in Groups A (n: 90; 24%), B (n: 105 (28%), C (n: 65; 17%), and D (n: 118; 31%). The mean AHIs of the Baveno groups were similar (p = 0.116). Oxygen desaturation index (ODI) was higher in Groups B and D compared to Group A. The duration of T90 desaturation was longer in Groups C and D compared to Groups A and B (p < 0.05). CONCLUSIONS: The Baveno classification divided our OSAS cases into equivalent groups. One out of every four patients with mild OSAS was in Group D. This data was noteworthy in that the Baveno classification allows for the identification of symptomatic and comorbid patients with mild OSAS according to AHI and for the application of more effective treatments to these patients. Patients with comorbidities experienced oxygen desaturation for a longer period of time at night, and oxygenation deteriorated in patients with prominent symptoms. Baveno classification was found to be a more reasonable and easily applicable approach in clinical practice.

NoSAS score predicts cardiovascular disease in patients with obstructive sleep apnea.

PURPOSE: The Lausanne NoSAS (Neck circumference, Obesity, Snoring, Age, Sex) score is a new tool for the identification of high-risk patients for obstructive sleep apnea (OSA). Up to now, no study has attempted to determine the role of NoSAS score in cardiovascular morbidity of patients with OSA. We aimed to investigate the relationships between NoSAS scores and CVD and also between severity of OSA, polysomnographic parameters, and NoSAS scores in patients with OSA. METHODS: Patients with diagnosis of OSA by full-night polysomnography were recruited in the study. Based on apnea-hypopnea index (AHI) scores, the patients were categorized as OSA-negative (AHI < 5), mild OSA (5 ≤ AHI < 15), moderate OSA (15 ≤ AHI < 30), and severe OSA (AHI ≥ 30). The definition of cardiovascular diseases (CVD) included the presence of any of the diseases such as hypertension, coronary artery disease, heart failure, or arrhythmia. RESULTS: A total of 1514 patients including cases with 199 OSA-negative, 391 mild, 342 moderate, and 582 severe OSA were enrolled in the study. NoSAS scores were significantly different between mild, moderate, and severe OSA groups. NoSAS scores were negatively correlated with minimum oxygen saturation values and positively with AHI and ODI (oxygen desaturation index) values (P < 0.001). NoSAS scores were significantly higher in patients with CVD, diabetes mellitus, and cerebrovascular disease compared with those without (P < 0.005). NoSAS cut-off values for hypertension (14), congestive heart failure (8.5), coronary artery disease (9), cerebrovascular event (11), and diabetes mellitus (10) were also determined. CONCLUSION: NoSAS scores are associated with CVD and the severity of OSA. NoSAS scores may be useful to predict CVD in patients with OSA.

Total Lesion Glycolysis Obtained by FDG PET/CT in Diagnosing Solitary Pulmonary Nodules.

OBJECTIVE: To evaluate the diagnostic performance of total lesion glycolysis (TLG) obtained by 18F-FDG PET/ CT to differentiate malignant solitary pulmonary nodules (SPNs) from benign ones. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Nuclear Medicine, Istanbul Medeniyet University School of Medicine, Istanbul, Turkey, from January 2018 to April 2022. METHODOLOGY: Eighty patients, who were found to have SPNs and underwent PET/CT imaging, were enrolled in this retrospective study. Parameters of PET-CT such as metabolic, volumetric, and metabolovolumetric were assessed concerning diagnostic value. Moreover, maximum standard uptake value (SUVmax) and TLG were combined and compared to improve diagnostic accuracy. RESULTS: The number of the detected benign and malignant SPNs was 38 and 42, respectively. Compared to the benign lesions, the malignant nodules presented significantly higher values in terms of SUVmax, TLG, and the volumes of metabolic tumour (MTV) and CT. Considering all parameters, the highest area under the curve (AUC) was occupied by TLG and SUVmax. The values for the sensitivity, specificity, and accuracy of SUVmax, TLG, and SUVmax combined with TLG were as follows respectively: 97.6%, 63.2%, and 81.2%; 85.7%, 92.1%, and 88.7%; and 85.7%, 94.7%, and 90%. CONCLUSION: The conventional value of SUVmax does not yield satisfactory results in order to separate the malignant nodules from the benign ones. The SUVmax value could be more valuable if it is used with TLG measurement in diagnosing SPNs. KEY WORDS: 18F-FDG PET/CT, SUVmax, TLG, Pulmonary nodule.

Evaluation of pulmonary involvement in systemic rheumatic diseases with high resolution computed tomography and pulmonary function test: A single-center experience.

INTRODUCTION: The objective of this study was to investigate the clinical and radiological features and pulmonary function tests (PFTs) in patients with the pulmonary involvement of systemic rheumatic diseases (SRDs). MATERIALS AND METHODS: This study was conducted as a retrospective and single-center study. Patients diagnosed with an SRD and admitted/referred to the department of chest diseases of our hospital between January 2015 and June 2019 were enrolled. All patients were evaluated using High Resolution Computed Tomography (HRCT) and PFT. RESULT: This study included 68 patients (15 males, 53 females) with a mean age of 62.38 ± 12.4 years. Forty-one (60.2%) patients had diagnosis of rheumatoid arthritis (RA), 10 (14.7%) patients had sjögren's syndrome (SS), 8 (11.7%) patients had systemic lupus erythematosus (SLE), 6 (8.8%) patients had systemic sclerosis (SSc), and 3 (4.4%) patients had mixed connective tissue disease (MCTD). While RA, SLE, MCTD patients were more commonly symptomatic, most of the SS patients were asymptomatic. Overall, 30 (44.1%) patients had normal PFT. Although 30 (%44.1) patients were asymptomatic and 30 (%44.1) patients had normal PFTs, at least one imaging finding was found in all patients according to HRCT imaging. "Bronchiectasis" was the most common HRCT finding in RA, followed by "chronic fibrotic changes" and "peribronchial thickening". "Chronic fibrotic changes" and "peribronchial thickening" were the most common changes in SS. Similarly, "peribronchial thickening" was the most common radiologic finding in SLE. As for SSc, "chronic fibrotic changes", "interlobular septal thickening", and "pleural effusion" were the most common radiologic findings. CONCLUSIONS: Pulmonary involvement in systemic rheumatic diseases can occur with various radiological images even in asymptomatic patients. PFTs can be normal as well as an obstructive, restrictive or mixed pattern can be seen. Heterogeneous and combined HRCT findings can be seen in SRD patients.

Usefulness of dynamic fluorodeoxyglucose positron emission tomography/computed tomography in diagnosing pulmonary arteriovenous malformation mimicking a lung tumour.

A 61-year-old male patient with known kidney dysfunction who underwent a non-contrast thorax CT and was then referred to our department for metabolic assessment of solitary pulmonary nodule (SPN). The patient underwent dynamic FDG PET/CT to differentiate benign from malignant SPN. This case illustrates the usefulness of dynamic FDG PET/CT imaging when assessing SPN especially in patients with suspicion for pulmonary arterio-venous malformation accompanying renal failure or contrast allergy.

The effect of tocilizumab on severe COVID-19 infection: Review of current evidence.

The COVID-19 outbreak that spread in December 2019 has caused the death of millions of people in a short time. Many studies published recently have shown that many cytokines (interleukin (IL) IL-1, IL-2, IL-6, TNF and IFN-) are significantly increased in COVID-19 patients with pneumonia, and especially IL-6 in combination with other cytokines has shown to be the main cause of the cytokine storm. Since IL-6 level is associated with clinical worsening in COVID-19 patients, anti-IL-6 therapy is seen as a promising treatment. Tocilizumab, a widely used IL-6 antagonist, was approved by the FDA in 2017 for Cytokine Storm Syndrome (CSS). Its addition to the treatment in COVID19 patients with increased blood IL-6 levels and oxygen saturation.

A new predictor to determine the exacerbation and treatment of chronic obstructive pulmonary disease: eosinophil/neutrophil ratio.

INTRODUCTION: COPD is an inflammatory disease characterized by persistent respiratory symptoms and airflow limitation. Currently, it has been demonstrated in some studies that eosinophil and T helper-2 mediated inflammation play a role in the pathophysiology of COPD. MATERIALS AND METHODS: It was planned to evaluate eosinophilia, eosinophil/ neutrophil ratio (ENR), distribution of ENR according to GOLD groups, number of exacerbations in last year, relationship between ENR and the rate of ICS use in COPD patients, and the ENR cut-off value that predicts eosinophilic COPD. This study was planned prospectively in stable COPD patients between July 2017 and December 2017. All patients were divided into two groups as eosinophilic and non-eosinophilic group. Eosinophilia was considered to be > 2% of peripheric blood eosinophils. RESULT: A total of 206 stable COPD patients (127 eosinophilic and 79 noneosinophilic) were included. Age, gender, BMI, smoking history, mMrc score were statistically similar while average pack-year of smoking was significantly higher in eosinophilic group. ENR was significantly higher in eosinophilic group as expected (p<0.001). High positive correlation was found between ENR and eosinophilic COPD (r= 0.8, p<0.001). In Group D, the number of eosinophilic COPD patients is significantly higher than the non-eosinophilic group while the distribution of patients in group A, B, C was similar. Although the PFT findings were similar in both groups, the use of ICS was significantly lower and the number of exacerbations was significantly higher in eosinophilic group. In the ROC analysis, the ENR cut-off value that predicts eosinophilic COPD was found to be 0.32 in all COPD patients (Sens: 93.7%, Specif: 92.4%, AUC= 0.97, p<0.001). CONCLUSIONS: Based on these findings, it is considered that more priority should be given to the use of ICS in COPD patients with high ENR and it can be used as a marker for predicting COPD exacerbation as COPD exacerbations are higher in patients with ENR.

Influence of comorbidities in long-term survival of chronic obstructive pulmonary disease patients.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality and morbidity around the world, with comorbidities in COPD being common and having a negative effect on survival. We investigate the effects of comorbidities on long-term survival of COPD patients. METHODS: The study included patients with COPD who were hospitalized with an exacerbation. The demographic characteristics, hematological and biochemical parameters, pulmonary function test parameters and comorbidities of the patients were obtained from the hospital database and patient records, and the mortality of the patients was assessed at two years. The parameters considered to be related to mortality were analyzed using the Cox regression method. RESULTS: A total of 826 patients with COPD were included in the study, and the rate of patients with at least one comorbidity was 84.5%. The most common comorbidities were hypertension (n=394, 47.7%), heart failure (n=244, 29.5%) and DM (n=173, 20.9%). In a Cox regression analysis, the Charlson Comorbidity Index was strongly associated with mortality (P=0.000). In Kaplan-Meier analysis, a significant association was noted between the increasing number of comorbidities and long-term mortality, when compared to the patients without comorbidity (comorbidity numbers 1, 2 and ≥3; HR: 1.37, P=0.032, HR: 1.40, P=0.028 and HR: 1.65, P=0.000, respectively). CONCLUSIONS: Increasing number of comorbidities in COPD patients with severe exacerbation were found to negatively affect long-term survival. We consider both the evaluation and treatment of comorbidities to be important in the reduction of long-term mortality in patients with COPD.

Serum heparanase levels are associated with endothelial dysfunction in patients with obstructive sleep apnea.

BACKGROUND AND AIM: Obstructive sleep apnea syndrome (OSAS) is well-known to be associated with high risk for cardiovascular (CV) diseases. Heparanase has been recently shown to be related to increased inflammation and vulnerability of the atherosclerotic plaques. Herein we aimed to investigate the relationships between OSAS, heparanase and endothelial dysfunction. MATERIALS AND METHODS: A total of 120 patients with varying severity of OSAS and 31 controls without OSAS were enrolled. Flow-mediated dilatation (FMD) was measured as an indicator of endothelial dysfunction. Serum heparanase levels were measured with ELISA. RESULTS: Serum heparanase levels increased in a stepwise fashion from controls to patients with more severe OSAS. When FMD was compared with controls and various degrees of severity of OSAS, a stepwise decrease in FMD was observed. Serum heparanase levels were found to be significantly associated with apnea hypopnea index (AHI) (r = .57, P < .001) and FMD (r= -.37, P < .001) in patients with OSAS. Serum heparanase levels were significantly associated with hemoglobin-A1c and body mass index in patients with OSAS. Serum heparanase and uric acid levels were independent predictors of FMD in linear regression analysis (R2 = .506, P < .001; P < .001 and P = .001 respectively). CONCLUSIONS: Serum heparanase levels were significantly increased in patients with OSAS and associated with the severity of OSAS (AHI) and endothelial dysfunction (FMD). Increased heparanase activity in OSAS may be related to increased cardiovascular risk in patients with OSAS.

Coronary flow reserve is reduced in sarcoidosis.

BACKGROUND AND AIMS: Sarcoidosis is a multisystem disease with frequent cardiac involvement, albeit manifest cardiac disease is rare. Though epicardial coronary arteries are not frequently involved, microvascular disease is rather common in both symptomatic and asymptomatic patients. The mechanism of microvascular involvement has not been elaborated yet. The aim of this study is to investigate coronary flow velocity reserve (CFVR) using transthoracic echocardiography in patients with sarcoidosis but without known atherosclerotic coronary artery disease or risk factors for atherosclerosis. METHODS: A total of 40 patients with sarcoidosis and 42 healthy volunteers without any known medical conditions were enrolled prospectively. Diastolic peak coronary flow velocities were measured during rest and maximal hyperemia induced with adenosine. RESULTS: Patients within the sarcoidosis group had significantly higher diastolic peak velocity at rest (29.5 ± 5.8 vs. 22.8 ± 3.2, p < 0.01) but both the diastolic peak velocity during hyperemia (60.5 ± 18.2 vs. 68.9 ± 15.7, p = 0.03) and CFVR (2.08 ± 0.57 vs. 3.03 ± 0.60, p < 0.01) were lower compared to controls. Sarcoidosis was an independent predictor for low (≤2.0) CFVR (OR: 56.8, 95%CI: 6.1-531.7, p < 0.001), along with age and systolic blood pressure. For patients with sarcoidosis, age and systolic blood pressure were independent predictors for a low CFVR. CONCLUSIONS: Despite a lack of known risk factors for atherosclerosis, patients with sarcoidosis had lower CFVR compared to healthy controls, thus suggesting a dysfunction in the coronary microvasculature. A reduced response to vasodilators suggests possible structural alterations of the myocardial microvasculature, rather than being secondary to microvascular spasm as suggested previously.

The role of tuberculosis in COPD.

BACKGROUND: Influence of tuberculosis (TB) on the natural course of COPD has not been well known. This study was designed to investigate the effects of history of TB on the long-term course of COPD. METHODS: Patients hospitalized with COPD exacerbation were consecutively included (n=598). Cases were classified into two categories: those with TB history and those without. Clinical, demographic, and radiological features were meticulously recorded, and patients were followed up for hospitalizations due to exacerbation and for overall mortality. RESULTS: A total of 93 patients (15%) had a history of TB. On average, patients with past TB history were 4 years younger than the rest of the patients (P=0.002). Our study revealed that patients with past TB were diagnosed with COPD 4 years earlier and died 5 years earlier as compared to the patients without TB. In addition, in the past TB group, rate of hospital admissions per year was higher compared to the group that lacked TB history (2.46±0.26 vs 1.56±0.88; P=0.001). Past TB group had higher arterial carbon dioxide tension (PaCO2) and lower forced expiratory volume in 1 second (FEV1; P=0.008 and P=0.069, respectively). Median survival was 24 months for patients who had past TB and 36 months for those who had not. Kaplan-Meier analysis revealed that although 3-year survival rate was lower in patients with past TB, it was not statistically significant (P=0.08). Cox regression analysis showed that while factors such as age, PaCO2, hematocrit, body mass index (BMI) and Charlson index affected mortality rates in COPD patients (P<0.05), prior history of TB did not. CONCLUSION: Our results showed that a history of TB caused more hospitalizations, reduced respiratory functions and increased PaCO2. It was found that, despite similarity of the overall mortality, COPD diagnosis and death occurred 5 years earlier in patients with past TB. We conclude that history of TB has an important role in the natural course of COPD.

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.