Deep learning for diagnosis of malign pleural effusion on computed tomography images

BACKGROUND

The pleura is a serous membrane that surrounds the lungs. The visceral surface secretes fluid into the serous cavity and the parietal surface ensures a regular absorption of this fluid. If this balance is disturbed, fluid accumulation occurs in the pleural space called "Pleural Effusion". Today, accurate diagnosis of pleural diseases is becoming more critical, as advances in treatment protocols have contributed positively to prognosis. Our aim is to perform computer-aided numerical analysis of Computed Tomography (CT) images from patients showing pleural effusion images on CT and to examine the prediction of malignant/benign distinction using deep learning by comparing with the cytology results.

METHODS

The authors classified 408 CT images from 64 patients whose etiology of pleural effusion was investigated using the deep learning method. 378 of the images were used for the training of the system; 15 malignant and 15 benign CT images, which were not included in the training group, were used as the test.

RESULTS

Among the 30 test images evaluated in the system; 14 of 15 malignant patients and 13 of 15 benign patients were estimated with correct diagnosis (PPD: 93.3%, NPD: 86.67%, Sensitivity: 87.5%, Specificity: 92.86%).

CONCLUSION

Advances in computer-aided diagnostic analysis of CT images and obtaining a pre-diagnosis of pleural fluid may reduce the need for interventional procedures by guiding physicians about which patients may have malignancies. Thus, it is cost and time-saving in patient management, allowing earlier diagnosis and treatment.

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.

The value of the platelet count and platelet indices in differentiation of COVID-19 and influenza pneumonia

It is difficult to distinguish coronavirus disease-2019 (COVID-19) from other viral respiratory tract infections owing to the similarities in clinical and radiological findings. This study aims to determine the clinical importance of platelet count and platelet indices in the differentiation of COVID-19 from influenza and the value of these parameters in the differential diagnosis of COVID-19. The medical records of the patients and the electronic patient monitoring system were retrospectively analyzed. Demographic characteristics, admission symptoms, laboratory findings, radiological involvement, comorbidities, and mortality of the patients were recorded. Forty-three patients diagnosed with influenza and 54 diagnosed with COVID-19 were included in the study. The average age of the COVID-19 patients was lower than that of the influenza patients (influenza: 60.5 years, COVID-19: 52.4 years; pp = 0.024),.024), and the male gender was predominant in the COVID-19 group (influenza: 42%, COVID-19: 56%). According to laboratory findings, the mean platelet volume (MPV) and MPV/platelet ratio were statistically significantly lower, whereas the eosinophil count and platelet distribution width levels were significantly higher (p < 0.05) in the COVID-19 group. It was found that the most common symptom in both groups was dyspnea and that the symptom was more prevalent among influenza patients. In the diagnosis of COVID-19, the platelet count and platelet indices are easily accessible, inexpensive, and important parameters in terms of differential diagnosis and can help in the differentiation of COVID-19 from influenza during seasonal outbreaks of the latter.

Prevalence of non-thyroidal illness syndrome in COPD exacerbation and effect of hypoxaemia and hypercapnia on thyroid functions

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease showing acute exacerbations during its course. Comorbidities often accompany. Non-thyroidal illness syndrome (NTIS) occurs because of the functional impairment in the hypothalamic-pituitary-thyroid axis in severe critical cases. The objective of the current study is to determine the prevalence of NTIS among hospitalised patients due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and to reveal the factors affecting thyroid functions.

MATERIALS AND METHODS

A total of 132 patients hospitalised for AECOPD were enroled. Arterial blood gas samples at room air and venous blood samples for thyroid function tests were obtained within 24 hours following hospitalisation.

RESULTS

The mean age was 69.3 ± 9.6 years with male predominance (M/F:130/2). The prevalence of NTIS was 55%. Subgroups of NTIS cases were analysed. Low TSH levels were the most common pathology (55%). Patients with NTIS had significantly lower PaO₂ and SaO₂ levels compared with those without NTIS (P = 0.045 and P = 0.022, respectively). In addition, a positive correlation was found between PaO₂ and free thyroxine (fT4) (P < 0.001, r = 0.313). A statistically significant negative correlation between PaCO₂ and fT4 was found (P < 0.001, r = -0.393). And a statistically significant negative correlation between PaCO₂ and free triiodothyronine (fT3) values were found (P = 0.040, r = -0.183).

CONCLUSION

NTIS is a very common condition during AECOPD. We believe that hypoxemia causing functional impairment in the hypothalamic-pituitary-thyroid axis is the main mechanism in NTIS development and hypercapnia disrupts freeT3 and freeT4 production and secretion.

Syncope as a subject of the risk assessment of pulmonary thromboembolism to be used for: A cross-sectional study

INTRODUCTION

Syncope is infrequent in pulmonary thromboembolism (PTE) yet might be indicative of haemodynamic instability. The prognostic role of syncope in PTE has not been well documented.

OBJECTIVES

In this study, the association between risk classification of the European Society of Cardiology and syncope was investigated in the normotensive PTE patients.

METHODS

We retrospectively screened electronic medical records of patients who were admitted in 2 tertiary care hospital and diagnosis of PTE with computed tomography pulmonary angiography. Patients with hypotension (high risk) at the time of admission were excluded from the study.

RESULTS

Of 5% patients (16/322) had syncope with the proportion of 81.3% (13/16) in the intermediate high risky group, 18.7% (3/16) in intermediate low risk group and 0% in low risk group. Mortality rate was higher in subjects with syncope (25% vs 11.1%) although it was not it was not statistically significant (P = NS). In those with syncope, the central venous thrombus was more frequent than those without it (78.6% vs 30.1%, P = .008). Only heart rate and intermediate high-risk group were retained as independent predictors of syncope selection in the multivariate logistic regression.

CONCLUSION

Although syncope is positively correlated with the severity of PTE, it does not predict the prognosis alone. Nonetheless, syncope in patients with PTE can be considered as an important alarming stimulus for clinical course.

Differences in biological traits composition of benthic assemblages between unimpacted habitats

There is an implicit requirement under contemporary policy drivers to understand the characteristics of benthic communities under anthropogenically-unimpacted scenarios. We used a trait-based approach on a large dataset from across the European shelf to determine how functional characteristics of unimpacted benthic assemblages vary between different sedimentary habitats. Assemblages in deep, muddy environments unaffected by anthropogenic disturbance show increased proportions of downward conveyors and surface deposit-feeders, while burrowing, diffusive mixing, scavenging and predation traits assume greater numerical proportions in shallower habitats. Deep, coarser sediments are numerically more dominated by sessile, upward conveyors and suspension feeders. In contrast, unimpacted assemblages of coarse sediments in shallower regions are proportionally dominated by the diffusive mixers, burrowers, scavengers and predators. Finally, assemblages of gravelly sediments exhibit a relatively greater numerical dominance of non-bioturbators and asexual reproducers. These findings may be used to form the basis of ranking habitats along a functional sensitivity gradient.

Soluble urokinase-type plasminogen activator receptor is a novel biomarker predicting acute exacerbation in COPD

Background

Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory condition, and progresses with acute exacerbations. (AE). During AE, levels of acute phase reactants such as C-reactive protein (CRP) and inflammatory cells in the circulation increase. Soluble urokinase-type plasminogen activator receptor (suPAR) levels increase in acute viral and bacterial infections and in diseases involving chronic inflammation. The purpose of this study was to investigate the effectiveness of suPAR in predicting diagnosis of AE of COPD (AE-COPD) and response to treatment.

Methods

The study population consisted of 43 patients diagnosed with AE-COPD and 30 healthy controls. suPAR, CRP, and fibrinogen levels were measured on the first day of hospitalization and on the seventh day of treatment.

Results

We found that fibrinogen (P<0.001), CRP (P<0.001), and suPAR (P<0.001) were significantly higher in patients with AE-COPD than in healthy controls. Fibrinogen (P<0.001), CRP (P=0.001), and suPAR (P<0.001) were significantly decreased by the seventh day of treatment. However, the area under receiver operator characteristic curve showed that suPAR is superior to CRP and fibrinogen in distinguishing AE-COPD. There was a correlation between fibrinogen, CRP, and suPAR. However, only fibrinogen was a powerful predictor of suPAR in multiple linear regression. In multiple logistic regression, only suPAR and fibrinogen were strong predictors of AE-COPD (P=0.002 and P=0.014, respectively). Serum suPAR was negatively correlated with forced expiratory volume in 1 second (r=−478, P=0.001).

Conclusion

suPAR is a marker of acute inflammation. It is well correlated with such inflammation markers as CRP and fibrinogen. suPAR can be used as a predictor of AE-COPD and in monitoring response to treatment.

Association of serum magnesium levels with frequency of acute exacerbations in chronic obstructive pulmonary disease: a prospective study

BACKGROUND

The course of chronic obstructive pulmonary disease (COPD) is accompanied by acute exacerbations. The purpose of this study is to determine the association of serum magnesium level with acute exacerbations in COPD (COPD-AE).

MATERIALS AND METHODS

Eighty-nine patients hospitalized with COPD-AE were included. Hemogram, biochemical tests, and arterial blood gases were analyzed. Pulmonary function tests were performed in the stable period after discharge. Patients were followed up at 3 monthly periods for one year.

RESULTS

Mean age of the patients was 70.4 ± 7.8 (range 47-90) years. Mean number of COPD-AE during follow-up was 4.0 ± 3.6 (range 0-15). On Spearman correlation analysis there were significant negative correlations between number of COPD-AE and predicted FEV1% (P = 0.001), total protein (P = 0.024), globulin (P = 0.001), creatinine (P = 0.001), and uric acid levels (P = 0.036). There were also significant positive correlations between number of COPD-AE and serum magnesium level (P < 0.001) and platelet count (P = 0.043). According to linear regression analysis predicted FEV1% (P = 0.011), serum magnesium (P < 0.001), and globulin (P = 0.006) levels were independent predictors of number of COPD-AE.

CONCLUSIONS

In this small prospective observational study we found that serum magnesium level during exacerbation period was the most significant predictor of frequency of COPD-AE.

The clinical utility of pleural YKL-40 levels in diagnosing pleural effusions

BACKGROUND AND OBJECTIVE

Recent evidence suggests that YKL-40 is a relatively new biomarker of inflammation and it is involved in the pathogenesis of several pulmonary diseases. Details of serum and pleural YKL-40 in pleural effusions however, remain unknown. We aimed to assess whether serum and pleural YKL-40 is an accurate biomarker of pleural effusions.

METHODS

This clinical study was prospective, observational and cross-sectional. The concentrations of serum and pleural fluid YKL-40 and conventional pleural marker levels were measured in 80 subjects with pleural effusions, including 23 transudates caused by congestive heart failure (CHF), and 57 exudates including 23 parapneumonic, 22 malignant and 12 tuberculous pleural effusions (TBPEs).

RESULTS

Median pleural fluid YKL-40 levels were higher in exudates than in transudates (219.4 and 205.9 ng/mL, respectively, P<0.001). High pleural YKL-40 levels, with a cutoff value of >215 ng/mL, yielded a 73% sensitivity, 73% specificity, likelihood ratio 2.8 for diagnosing exudate, with an area under the curve of 0.770 [95% confidence intervals (CI): 0.657-0.884]. Pleural YKL-40/serum YKL-40 ratio >1.5 yielded a 75% sensitivity, 72% specificity and likelihood ratio 2.6 for diagnosing TBPE, with an area under the curve of 0.825 (95% CI: 0.710-0.940).

CONCLUSIONS

High concentrations of pleural YKL-40 level may help to differentiate exudate from transudate and a high pleural YKL-40/serum YKL-40 ratio may be helpful in seperating TBPE from non-tuberculous effusions.

High serum YKL-40 level in patients with COPD is related to hypoxemia and disease severity

Chronic obstructive pulmonary disease (COPD) is a major health problem with increasing morbidity and mortality throughout the world. YKL-40 is a chitin-binding glycoprotein consisting of 383 amino acids, with a molecular mass of 40 kDa, and its serum level is elevated in inflammatory diseases. YKL-40 is a newly recognized biomarker of inflammation and has not been thoroughly investigated in COPD. The aim of the study is to investigate the relationship between serum YKL-40 levels and severity of COPD. The study population consisted of 52 patients with COPD with the mean age of 60.2 ± 10.1 years. The serum YKL-40 level increased significantly with increasing age (p = 0.022, r = 0.346). In COPD patients, high serum YKL-40 level is correlated to low forced expiratory volume at 1 second (FEV₁, percent of predicted) (r = -0.277, p = 0.047). Moreover, high serum YKL-40 level is correlated to low arterial oxygen pressure (PaO₂, mmHg) (r = -0.387, p = 0.005). The mean serum YKL-40 level was found as 243.1 ± 129.2 ng/ml in COPD patients with desaturation during 6-minute walk test (6MWT) and this value was higher than the mean serum YKL-40 level (155.8 ± 59.1 ng/ml) of COPD patients without desaturation during 6MWT (p = 0.004). This study demonstrated that high serum YKL-40 levels were correlated to severity of COPD. We propose that circulating YKL-40 levels could be a biomarker for hypoxemia and decline in lung function.

Right sided arcus aorta as a cause of dyspnea and chronic cough

BACKGROUND

Right sided arcus aorta (RSAA) is a rare condition that is usually asymptomatic. Patients may present with exertional dyspnea and chronic cough. A recent article suggested that RSAA should be included in the differential diagnosis of asthma, especially in patients with intractable exertional dyspnea. We aimed to present the clinical, radiologic and spirometric features of thirteen patients with RSAA observed in four years at the Rize Education and Research Hospital and Samsun Chest Diseases and Thoracic Surgery Hospital.

METHODS

The characteristics of patients with RSAA, including age, gender, symptoms, radiologic and spirometric findings, were retrospectively evaluated.

RESULTS

A total of thirteen patients were diagnosed with RSAA. Their ages ranged from 17 to 86 years and the male to female ratio was 11:2. Seven of the patients (54%) were symptomatic. The most common symptoms were exertional dyspnea, dysphagia and chronic cough. Five patients had received treatment for asthma with bronchodilators. Spirometry showed intrathoracic tracheal obstruction in five patients.

CONCLUSIONS

The RSAA anomaly occurs more frequently than might be estimated from the number of patients who are detected. Patients with intractable exertional dyspnea and chronic cough should be evaluated for the RSAA anomaly by thoracic CT.

Right sided arcus aorta as a cause of dyspnea and chronic cough

Background: Right sided arcus aorta (RSAA) is a rare condition that is usually asymptomatic. Patients may present with exertional dyspnea and chronic cough. A recent article suggested that RSAA should be included in the differential diagnosis of asthma, especially in patients with intractable exertional dyspnea. We aimed to present the clinical, radiologic and spirometric features of thirteen patients with RSAA observed in four years at the Rize Education and Research Hospital and Samsun Chest Diseases and Thoracic Surgery Hospital. Methods: The characteristics of patients with RSAA, including age, gender, symptoms, radiologic and spirometric findings, were retrospectively evaluated. Results: A total of thirteen patients were diagnosed with RSAA. Their ages ranged from 17 to 86 years and the male to female ratio was 11:2. Seven of the patients (54%) were symptomatic. The most common symptoms were exertional dyspnea, dysphagia and chronic cough. Five patients had received treatment for asthma with bronchodilators. Spirometry showed intrathoracic tracheal obstruction in five patients. Conclusions: The RSAA anomaly occurs more frequently than might be estimated from the number of patients who are detected. Patients with intractable exertional dyspnea and chronic cough should be evaluated for the RSAA anomaly by thoracic CT.

In situ thrombosis in pulmonary arterial aneurysms due to Behçet’s disease and efficacy of ımmunosuppressive therapy

BehçetDisease (BD) is a systemic vasculitis characterized by recurrent oral and genital ulcers and uveitis, arthritis, and involvement of the gastrointestinal tract, central nervous system and blood vessels. The aneurysms of the pulmonary arteries, with or without thrombosis, are typical manifestation of BD. We report a case with BD, pulmonary arterial aneurysms(PAA) and in situ thrombosis. We aimed to show the effectiveness of immunosuppressive treatment on in situ thrombosis in a case with PAA and BD.

In situ thrombosis in pulmonary arterial aneurysms due to Behçet's disease and efficacy of ımmunosuppressive therapy

BehçetDisease (BD) is a systemic vasculitis characterized by recurrent oral and genital ulcers and uveitis, arthritis, and involvement of the gastrointestinal tract, central nervous system and blood vessels. The aneurysms of the pulmonary arteries, with or without thrombosis, are typical manifestation of BD. We report a case with BD, pulmonary arterial aneurysms(PAA) and in situ thrombosis. We aimed to show the effectiveness of immunosuppressive treatment on in situ thrombosis in a case with PAA and BD.

Skinsarcoidosis: A trick for primary case physicians

Sarcoidosis is a systemic disease of unknown etiology. Skin lesions occur in about a quarter of patients with sarcoidosis and specific manifestations include erythema nodosum, maculopapular eruption, plaques, lupus pernio and scar sarcoidosis. A 39-year old male presented with cutaneous involvement of sarcoidosis. The skin biopsy revealed non-caseating granuloma. Our patient had skin manifestation of makulopapular eruption form of skinsarcoidosis along with hilar and mediastinal lymphadenopathy. The 40 mg/day oral methylprednisolone was started and skin lesions were fully recovered. We report a case of skin involvement as a first sign of sarcoidosis.

Recursive Partitioning Analysis of Mediastinal N2 Lymph Node Involvement with Selected Biological Markers in Operable Non-small Cell Lung Cancer: A Correlative Study

BACKGROUND

Expressions of various biomarkers in non-small cell lung cancer (NSCLC) have been linked with the prognosis and involvement of mediastinal lymph nodes.

METHODS

In this study, we utilized recursive partitioning analysis (RPA) by using P53, c-erb-B2, and P-glycoprotein (PGP) expressions evaluated by immunohistochemistry to estimate retrospectively the likelihood of the occult N2 mediastinal lymph node involvement in patients with operable NSCLC.

RESULTS

In univariate tests, immunohistochemical staining of the primary tumor for these 3 markers in 61 patients undergoing surgery revealed no direct relationship with the N2 involvement. However, RPA demonstrated in patients aged <75 and with >/=4 mediastinal lymph nodes removed that, high PGP expression frequency (>/=20%) predicted an increased likelihood of the N2 involvement (46.7%, R(2) = 0.25). Univariate nominal logistic regression analysis revealed that RPA group affiliation, and the number of mediastinal lymph nodes resected (logarithmic transformation) were associated with the metastasis to N2 lymph nodes (chi(2) = 17.59, p = 0.0005, and chi(2) = 2.40, p = 0.0654, respectively). Multivariate analysis confirmed that only RPA group affiliation predicted the N2 involvement (chi(2) = 14.63, p = 0.0022).

CONCLUSION

This study shows for the first time that PGP expression of the primary tumor may help to predict the occult N2 mediastinal lymph node involvement in NSCLC. Thus, further research is required to understand whether PGP expression may aid in the decision process for preoperative mediastinoscopy.

Recursive Partitioning Analysis of Mediastinal N2 Lymph Node Involvement with Selected Biological Markers in Operable Non-small Cell Lung Cancer: A Correlative Study

Background

Expressions of various biomarkers in non-small cell lung cancer (NSCLC) have been linked with the prognosis and involvement of mediastinal lymph nodes.

Methods

In this study, we utilized recursive partitioning analysis (RPA) by using P53, c-erb-B2, and P-glycoprotein (PGP) expressions evaluated by immunohistochemistry to estimate retrospectively the likelihood of the occult N2 mediastinal lymph node involvement in patients with operable NSCLC.

Results

In univariate tests, immunohistochemical staining of the primary tumor for these 3 markers in 61 patients undergoing surgery revealed no direct relationship with the N2 involvement. However, RPA demonstrated in patients aged <75 and with ≥4 mediastinal lymph nodes removed that, high PGP expression frequency (≥20%) predicted an increased likelihood of the N2 involvement (46.7%, R2 = 0.25). Univariate nominal logistic regression analysis revealed that RPA group affiliation, and the number of mediastinal lymph nodes resected (logarithmic transformation) were associated with the metastasis to N2 lymph nodes (χ2 = 17.59, p = 0.0005, and χ2 = 2.40, p = 0.0654, respectively). Multivariate analysis confirmed that only RPA group affiliation predicted the N2 involvement (χ2 = 14.63, p = 0.0022).

Conclusion

This study shows for the first time that PGP expression of the primary tumor may help to predict the occult N2 mediastinal lymph node involvement in NSCLC. Thus, further research is required to understand whether PGP expression may aid in the decision process for preoperative mediastinoscopy.

Cluster analysis of p-glycoprotein, c-erb-B2 and P53 in relation to tumor histology strongly indicates prognosis in patients with operable non-small cell lung cancer

BACKGROUND

Various biomarkers have prognostic value in non-small cell lung cancer (NSCLC). We aimed to identify the roles of P53, c-erb- B2 and p-glycoprotein (pgp) as prognostic factors, independently or in conjunction with each other, in operable NSCLC.

MATERIAL/METHODS

Seventy operable NSCLC cases were retrospectively evaluated for P53, c-erb-B2 and pgp expression patterns by immunohistochemistry. An unsupervised hierarchical cluster analysis of the 3 biomarkers was conducted. Univariate and multivariate survival analyses were made in relation to cluster affiliation.

RESULTS

Cluster analysis yielded two distinct subgroups; group A of high biomarker expressors (n=26, 37%), and group B (n=44, 63%) of low expressors. Cluster affiliation with regard to tumor histology (interaction term) was independently associated with Recurrence- free survival (RFS) and Overall survival (OAS) with a Hazard Ratio (HR) of 5.88, P=0.003, and HR=4.68, P=0.012, respectively. The median OAS times for cluster A and B in the squamous cell carcinoma subgroup were 328 and 596 days, whereas the corresponding figures in the non-squamous cell carcinoma subgroup were non-measurable and 298 days.

CONCLUSIONS

In operable NSCLC there may be different relationships of P53, c-erb-B2 and pgp with patient outcome for different tumor histologies. The prognostic utility of cluster affiliation with regard to these biomarkers, and in relation to tumor histology, deserves further testing.