Agreement Between Transthoracic Echocardiography and Computed Tomography Pulmonary Angiography for Detection of Right Ventricular Dysfunction in Pulmonary Embolism.

BACKGROUND: Right ventricular dysfunction (RVD) is the main determinant of mortality in patients with pulmonary embolism (PE). Thus, guidelines recommend the assessment of RVD with transthoracic echocardiography (TTE) or computed tomography pulmonary angiography (CTPA) among these patients. In this study, we investigated the agreement between TTE and CTPA for the detection of RVD. METHODS: This single-center retrospective study included patients who were diagnosed with CTPA and underwent TTE within the first 24 hours following the diagnosis. RESULTS: Two hundred fifty-eight patients met the inclusion criteria. In 71.3% (184) of them, CTPA and TTE agreed on both the presence and absence of RVD. There was a moderate agreement between the 2 tests (Cohen's kappa = 0.404, P <.001). The agreement between right ventricle dysfunction on TTE and the increased right ventricle/left ventricle (RV/LV) on CTPA was fair (Cohen's kappa = 0.388, P <.001). Three patients died due to PE, and another 5 patients required urgent reperfusion therapy. Overall, adverse outcomes occurred in 4% (8) of patients. The sensitivity of modalities in the detection of adverse outcomes was 100%. Transthoracic echocardiography was more specific compared to CTPA (43% vs. 28%). Statistically, flattening/bulging of the interventricular septum on TTE was significantly associated with adverse outcomes. No individual CTPA parameter was related to adverse outcomes. CONCLUSION: Both CTPA and TTE are reliable imaging modalities in the detection of RVD. However, TTE is more specific, and this may help in the identification and appropriate management of patients at higher risk of decompensation. A combination of CTPA parameters rather than individual RV/LV ratios increases the sensitivity of CTPA.

Rheumatoid Arthritis-Related Lung Disease and Its Association With Mortality.

PURPOSE: The aim of this study was to determine the association of rheumatoid arthritis-related lung disease (RA-LD) and its subtypes with all-cause mortality. MATERIALS AND METHODS: For the present analyses, patients with RA who underwent computed tomography of the chest (chest-CT) were evaluated. RA-LD was defined in 4 subtypes as follows: interstitial lung disease (RA-ILD), airway disease (RA-AD), rheumatoid pulmonary nodules (RA-PN), and RA-related pleural disease (RA-PD). The date of RA-LD diagnosis was considered the date of the first chest-CT detecting the pathology. To assess the factors associated with mortality, multivariable logistic regression analyses were performed with variables selected based on their causal associations with the outcome. RESULTS: Of 576 RA patients, 253 (43.9%) had RA-LD (38.7% male; mean age at RA-LD diagnosis, 59.9 ± 9.8 years). The most common subtype was RA-AD, which was detected in 119 (47.0%) patients followed by 107 (42.3%) with RA-ILD, 70 (27.7%) with RA-PN, and 31 (12.3%) with RA-PD. Sixty-one (24.1%) patients had 2+ subtypes. After median follow-up of 10.2 years, 97 (16.8%) died. The existence of at least 1 subtype and 2+ subtypes increased the all-cause mortality, as indicated by odds ratios of 1.60 (95% confidence interval [CI], 1.03-2.48) and 2.39 (95% CI, 1.26-4.54), respectively. Among RA-LD patients, RA-ILD and RA-PD were associated with increased mortality (odds ratios were 2.20 [95% CI, 1.18-4.08] and 1.62 [95% CI, 0.70-3.75], respectively). CONCLUSIONS: In this study, RA-AD was the most common subtype, and the presence of RA-LD increased mortality. This effect was particularly pronounced in patients with RA-ILD and RA-PD or those presenting with 2+ subtypes.

Does anticoagulation in combination with immunosuppressive therapy prevent recurrent thrombosis in Behçet's disease?

Vascular involvement in Behçet's disease (BD) occurs in up to 50% of patients. The main mechanism of thrombosis is inflammation. Thus, immunosuppressants (IS) are the mainstay of therapy, and adding anticoagulation (AC) is controversial. In daily practice, we observed that patients who received AC in combination with IS experienced less recurrent thrombosis and decided to investigate our BD patients retrospectively. We hypothesized that adding AC to immunosuppressive therapy may lower the risk of recurrent thrombosis. Treatment at the time of first or recurrent thrombotic events was recorded. Events under the only IS and IS + AC treatments were compared. There were 40 patients (33 males). The most common types of first vascular events were deep vein thrombosis (77.5%) followed by pulmonary embolism (PE) (52.5%). One patient did not receive any treatment. Among the 39 patients, 32 received glucocorticoid and at least one of the azathioprine, or cyclophosphamide, anti-TNF, 5 received monotherapy with azathioprine, 1 received monotherapy with corticosteroid, and the remaining 1 received monotherapy with cyclophosphamide. In total, 22 patients (55%) experienced 27 recurrent venous thromboembolism (VTE) events. Two (7.4%) events while only on AC, 2 (7.4%) events while on AC + IS, and 15 (55.5%) events occurred while on only IS. Eight (19.6%) patients were not receiving any treatment during relapses. The recurrence rate was statistically significantly lower in the IS + AC treatment group compared to IS alone. In conclusion, IS are the mainstay of treatment for BD, and adding AC may help to lower the recurrence risk of thrombotic events.

Can the generalizability issue of artificial intelligence be overcome? Pneumothorax detection algorithm.

The generalizability of artificial intelligence (AI) models is a major issue in the field of AI applications. Therefore, we aimed to overcome the generalizability problem of an AI model developed for a particular center for pneumothorax detection using a small dataset for external validation. Chest radiographs of patients diagnosed with pneumothorax (n = 648) and those without pneumothorax (n = 650) who visited the Ankara University Faculty of Medicine (AUFM; center 1) were obtained. A deep learning-based pneumothorax detection algorithm (PDA-Alpha) was developed using the AUFM dataset. For implementation at the Health Sciences University (HSU; center 2), PDA-Beta was developed through external validation of PDA-Alpha using 50 radiographs with pneumothorax obtained from HSU. Both PDA algorithms were assessed using the HSU test dataset (n = 200) containing 50 pneumothorax and 150 non-pneumothorax radiographs. We compared the results generated by the algorithms with those of physicians to demonstrate the reliability of the results. The areas under the curve for PDA-Alpha and PDA-Beta were 0.993 (95% confidence interval (CI): 0.985-1.000) and 0.986 (95% CI: 0.962-1.000), respectively. Both algorithms successfully detected the presence of pneumothorax on 49/50 radiographs; however, PDA-Alpha had seven false-positive predictions, whereas PDA-Beta had one. The positive predictive value increased from 0.525 to 0.886 after external validation (p = 0.041). The physicians' sensitivity and specificity for detecting pneumothorax were 0.585 and 0.988, respectively. The performance scores of the algorithms were increased with a small dataset; however, further studies are required to determine the optimal amount of external validation data to fully address the generalizability issue.

Prognosis of sarcoidosis and factors affecting prognosis.

INTRODUCTION: Sarcoidosis is a multi-system disease of unknown etiology characterized by non-caseating granulomatous inflammation. Determining the characteristics and prognosis of sarcoidosis cases and revealing the factors that may affect the prognosis are important for approach to patient. This study was planned to obtain prognosis data for our country and to determine the factors affecting the prognosis. PATIENTS AND METHODS: 188 patients, followed regularly for three years or more, admitted to Ankara University Faculty of Medicine, Department of Chest Diseases between 2012-2017 were evaluated retrospectively. Increased radiological findings, functional impairment and any of the clinical conditions requiring initiation/modification of treatment were accepted as progression. Clinical status of the patients at the last follow-up was defined as remission with treatment, spontaneous remission, stable disease, progression, chronic case and recurrence. Spontaneous remission and remission with treatment, regression, stable disease, and recurrence that followed without treatment and didn't cause symptom or functional impairment were accepted in good prognosis group. Progression, chronic cases that couldn't be followed without treatment and recurrence requiring treatment were included in poor prognosis group. RESULTS: 58% of patients was accepted in good prognosis and 42% had poor prognosis group. During follow-up, spontaneous remission rate was 20.2%, pulmonary hypertension development rate was 10.6% and mortality rate was 4.25%. Low radiological stage, high spirometry and diffusion capacity values, being asymptomatic and having no previous treatment were associated with spontaneous remission and good prognosis. Increase in serum angiotensin converting enzyme and C-reactive protein and decrease in spirometry parameters and diffusion capacity values were associated with progression.

The role of serum and bronchoalveolar lavage fluid chitotriosidase activity on diagnosis, disease characteristics and prognosis of sarcoidosis.

Introduction: Sarcoidosis is a multisystem granulomatous disease with an unpredictable clinical course. Chitotriosidase is a chitinase mainly expressed by activated macrophages. Increased chitotriosidase activity has been reported in serum and bronchoalveolar lavage (BAL) of sarcoidosis patients compared to healthy controls. This study aims to evaluate the role of serum and BAL chitotriosidase activity on diagnosis, disease characteristics, and prognosis of sarcoidosis. Materials and Methods: Patients referred with suspected sarcoidosis or other interstitial lung disease were prospectively included in the study. All patients underwent bronchoscopy with BAL. Serum and BAL chitotriosidase activity, BAL differential cell counts, and lymphocyte phenotypes were determined. Sarcoidosis patients were followed up regularly. Result: Forty-two sarcoidosis and 28 non-sarcoidosis patients were included in the study. Serum chitotriosidase activity was higher in sarcoidosis group 247.5 (2.78-461) vs 108 (2.78-272) nmol/h/mL (p< 0.001). BAL chitotriosidase activity tended to be higher in sarcoidosis group 11 (2-308) vs 6.95 (2.27-44) nmol/h/mg but was not found to be statistically significant (p= 0.11). Serum and BAL chitotriosidase activities were correlated with each other (p= 0.023, r= 0.355). No significant difference was found between the diagnostic performance of BAL CD4/CD8 ratio and serum chitotriosidase activity (p= 0.079). Serum chitotriosidase and ACE activities were correlated with each other (p= 0.004, r= 0.457). No significant difference was found between serum or BAL chitotriosidase activity and stage or extrapulmonary involvement. Serum chitotriosidase activity was higher in patients who needed systemic therapy at diagnosis (p= 0.046). However, no significant difference was found between serum or BAL chitotriosidase activities and disease progression (p= 0.395 and p= 0.723, respectively). Conclusions: Serum chitotriosidase activity can be helpful in the differential diagnosis of sarcoidosis with a similar diagnostic performance with BAL CD4/CD8 ratio. Although serum chitotriosidase activity at diagnosis does not predict progressive disease, it is associated with the need for systemic therapy at diagnosis. Serial chitotriosidase measurements may be useful in monitoring disease progression during follow-up.

Interstitial lung disease associated with chronic liver disease.

It is important to make the differential diagnosis of restrictive changes associated with hepatic hydrothorax or hepatopulmonary syndrome seen in the later stages of chronic liver diseases and restrictive changes associated with interstitial lung disease. Lymphocytic interstitial pneumonia (LIP) is in the rare idiopathic interstitial pneumonia subgroup of interstitial lung diseases. LIP is a rare disease, and its incidence is unknown. LIP is characterized by infiltration of the alveolar interstitium with lymphocytes, plasma cells, and histiocytes. The etiology of LIP includes idiopathic causes, rheumatological diseases, immune deficiencies, viral infections, and drug-related causes. Chronic liver diseases are also rarely included in the etiology of LIP. A 75-year-old male patient who was followed up for liver cirrhosis presented with dyspnea. He had hypoxemia in the arterial blood gas. In the thorax and abdominal computed tomography, irregular reticulations in bilateral lungs, ground-glass opacities, and scattered air cysts in both lung parenchyma, chronic liver parenchymal disease, splenomegaly, chronic portal vein thrombosis were determined. Clinical and radiological changes in the patient were evaluated in favor of interstitial lung disease. Although histopathological diagnosis could not be made, the patient whose radiological pattern was compatible with LIP was evaluated together with clinical findings and was accepted as lymphocytic interstitial pneumonia. He was evaluated in terms of diseases that could cause LIP. He was accepted as LIP due to chronic liver disease. Although histopathological examination is the gold standard for the diagnosis, a biopsy could not be performed in our case. Radiological and clinical findings were considered sufficient for the diagnosis of LIP. Chronic viral hepatitis and cirrhosis are also present in the etiology of LIP. Our case is presented as an example in the literature because it is a case of LIP due to chronic liver disease, and it is rare.

Recovery from Respiratory Failure in Patients with Coronavirus Disease 2019.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) can cause hypoxic respiratory failure; long-term oxygen therapy (LTOT) duration is unknown. MATERIAL AND METHODS: The aim was to investigate which patients would need LTOT after COVID-19 pneumonia. This single-center, prospective study was conducted at the Ankara University Faculty of Medicine, Department of Chest Diseases, between May 2021 and December 2021. The 70 patients hospitalized for COVID-19 pneumonia and discharged with LTOT due to hypoxemic respiratory failure were included. Patients were divided into 2 groups as group I (LTOT requirement <3 months) and group II (LTOT requirement continued ≥3 months). RESULTS: The mean age was 64.4 ± 13.5 years, and 44 (62.9%) of them were male. The most frequently encountered comorbidities were cardiovascular disease (57.1%) and lung disease (22.9%). While PaO2 levels increased in both groups during the follow-up period, this increment was significantly higher in group I (PaO2: 66.6 ± 9.9 mm Hg, P < .001). The factors affecting the LTOT requirement were evaluated using binary logistic regression. On multivariate analyses of lymphocytes, ferritin, C-reactive protein, PaO2, SaO2, subpleural reticulation, and number of lobes affected (≥3 lobes), the SaO2 level and presence of subpleural reticulation were significantly different between the 2 groups [odds ratio (OR) (95% CI): 0.853 (0.749-0.971), P = .016] and [OR (95% CI): 0.171 (0.042-0.733), P = .017], respectively. CONCLUSION: A significant proportion of patients who develop respiratory failure due to COVID-19 recover within the first 3 months. Factors determining the LTOT requirement for more than 3 months were SaO2 and the presence of subpleural reticulation.

Clinical, Functional, and Prognostic Evaluation of Idiopathic Pulmonary Fibrosis, Connective Tissue Disease-Associated Interstitial Lung Disease, Interstitial Pneumonia with Autoimmune Features: A Single-Center Prospective Study.

OBJECTIVE: Our study aimed to evaluate clinical, functional, and prognostic features and to determine the prognosis of idiopathic pulmonary fibrosis, connective tissue disease-associated interstitial lung diseases, and interstitial pneumonia with autoimmune features. MATERIAL AND METHODS: Sixty-nine cases with interstitial lung diseases were recruited in this study prospectively. Demographic features, symptoms, radiological findings, functional measurements, and immunological markers were recorded twice (at the time of initial admission and in the 12th month). Twenty-four of 69 cases were idiopathic pulmonary fibrosis, 32 were connective tissue diseaseassociated interstitial lung diseases, and 13 were interstitial pneumonia with autoimmune features . RESULTS: Most of the patients with idiopathic pulmonary fibrosis were male, while there were more female patients in connective tissue disease-associated interstitial lung diseases and interstitial pneumonia with autoimmune features groups. Female patients (65.0%) predominated in connective tissue disease-associated interstitial lung diseases group (P <.001). There was no significant difference in the mean ages of the disease groups, yet connective tissue disease-associated interstitial lung diseases patients were generally younger (min- max: 34-82 years). In the idiopathic pulmonary fibrosis group, only low titers of antinuclear antibody positivity were found. Antinuclear antibody positivity in the connective tissue disease-associated interstitial lung diseases group and interstitial pneumonia with autoimmune features group was high (P = .001). The long-term survival of idiopathic pulmonary fibrosis, connective tissue disease-associated interstitial lung diseases, and interstitial pneumonia with autoimmune features patients were 37%, 40 months (median) (95% CI, 5.193- 74.807), 48.6%, 80 months (median) (95% CI, 57.032-102.968), 30.8%, 46 months (median) (95% CI, 26.624-65.376), respectively. CONCLUSION: Although a consensus report describing interstitial lung diseases with autoimmune features has been published, diagnostic criteria for this group are still vague. Since the interstitial pneumonia with autoimmune features group had the worst results in terms of functional loss and survival rates, the follow-up parameters and follow-up algorithm should be established for this group. Clinical and immunological evaluation of the interstitial pneumonia with autoimmune features group should include detailed parameters because of follow-up and to estimate survival.

Rituximab experience from a single centre for patients with rheumatoid arthritis-related interstitial lung disease.

Objective: To demonstrate the effects of rituximab (RTX) in patients with rheumatoid arthritis-related interstitial lung disease (RA-ILD). Methods: A total of 165 patients who used RTX for the management of rheumatoid arthritis were retrospectively scrutinised. Among these, 26 patients diagnosed with RA-ILD were analysed (61.5% male, mean age at RTX infusion 61.4 ± 6.5 years). To evaluate the efficacy of RTX on lung response, patients with pulmonary function test results and/or thorax computed tomography (chest-CT) of pre- and post-RTX were compared. Disease progression was defined as either a decline of ≥10% in forced vital capacity (FVC) and/or a decline of ≥15% in diffusion capacity of carbon monoxide (DLCO), or an increase of parenchymal involvement on chest-CT images according to the radiologists' assessment. Results: Among 26 patients, the most common radiologic pattern was usual interstitial pneumonia (42.3%), followed by non-specific interstitial pneumonia (38.5%). Data for lung response was available in 20 patients. Median pre- and post- RTX DLCO values were 71.0% (60.0-77.0) and 63.0% (47.0-74.0), respectively (p= 0.06). Median pre- and post-RTX FVC values were 74.0% (61.0-99.0) and 84.0% (63.0-100.0), respectively (p= 0.28). Overall, stabilization or regression of RA-ILD was provided in 13 (65.0%) patients, whereas 7 patients had progressive RA-ILD. Post-RTX, 5 patients were diagnosed with RA-ILD. Conclusion: Our results suggest that RTX is effective in achieving stabilization or even improvement of RA-ILD. However, considering that it does not cause regression in every patient and some develop RA-ILD under RTX, we still need more effective treatment options.

A Case of Amyopathic Dermatomyositis with Pneumomediastinum and Subcutaneous Emphysema.

A 34-year-old man was admitted with dyspnea, cough, and fever. Thorax computed tomography revealed ground glass opacities and pneumomediastinum. The patient was diagnosed as amyopathic dermatomyositis due to skin lesions and radiological findings. Despite immunosuppressive treatment clinical deterioration and radiological progression were observed and the patient died because of severe hypoxemic respiratory failure. The patient presented with extremely rare occurrence of pneumomediastinum and subcutaneous emphysema in amyopathic dermatomyositis with a poor prognosis.

Diagnosis of Invasive Fungal Diseases in Hematological Malignancies: A Critical Review of Evidence and Turkish Expert Opinion (TEO-2).

One of the most problematic issues in hematological malignancies is the diagnosis of invasive fungal diseases. Especially, the difficulty of mycological diagnosis and the necessity of immediate intervention in molds have led to the adoption of "surrogate markers" that do not verify but rather strongly suggest fungal infection. The markers commonly used are galactomannan (GM), beta-glucan, and imaging methods. Although there are numerous studies on these diagnostic approaches, none of these markers serve as a support for the clinician, as is the case in human immunodeficiency virus (HIV) or cytomegalovirus (CMV) infections. This paper has been prepared to explain the diagnostic tests. As molecular tests have not been standardized and are not used routinely in the clinics, they will not be mentioned here.

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

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

[Association of combined small cell and large cell lung cancer with Lambert-Eaton myasthenic syndrome: case report]. / Kombine küçük hücreli ve büyük hücreli akciger kanseri ile Lambert-Eaton miyastenik sendromu birlikteligi: Olgu sunumu.

Lambert-Eaton myasthenic syndrome (LEMS) is a rare type of neuromusculer conduction disorder. This disease can be seen with lung cancer and, it is associated with otoimmunity. Among the symptoms of lung cancer LEMS can be seen, but it is very rare. In this case, LEMS symptoms were analyzed before lung cancer symptoms. The localization of the tumor was near the pulmonary artery. By the early diagnose, the patient had the chance of cure.