Asthma-chronic obstructive pulmonary disease overlap: Results from a national-multicenter study

Introduction

Patients with asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) have a greater disease burden than those with COPD or asthma alone. In this study, it was aimed to determine the prevalence, risk factors, and clinical features of ACO because there are limited national data in Türkiye.

Materials and Methods

The study was conducted in a cross-sectional design in nine tertiary-care hospitals. The patients followed with a diagnosis of asthma or COPD for at least one year were enrolled in the study. The frequency of ACO and the characteristics of the patients were evaluated in the asthma and COPD groups.

Result

The study included 408 subjects (F/M= 205/203, mean age= 56.24 ± 11.85 years). The overall prevalence of ACO in both groups was 20.8% (n= 85). The frequency was higher in the COPD group than in the asthma group (n= 55; 33.3% vs. n= 22; 9.8%), respectively (p= 0.001). Patients with ACO had similarities to patients with COPD in terms of advanced age, sex, smoking, exposure to biomass during childhood, being born in rural areas, and radiologic features. Characteristics such as a history of childhood asthma and allergic rhinitis, presence of chronic sinusitis, NSAID hypersensitivity, atopy, and high eosinophil counts were similar to those of patients with asthma (p<0.001). The annual decline in FEV1 was more prominent in the ACO group (mean= -250 mL) than in the asthma (mean change= -60 mL) and COPD (mean change= -230 mL) groups (p= 0.003).

Conclusions

This study showed that ACO was common among patients with asthma and COPD in tertiary care clinics in our country. ACO should be considered in patients with asthma and COPD who exhibit the abovementioned symptoms.

Respiratory Muscle Endurance in Obesity Hypoventilation Syndrome

BACKGROUND

An increase in respiratory work load and resistance to respiration cause a decrease in respiratory muscle endurance (RME) in patients with obesity hypoventilation syndrome (OHS). We aimed to evaluate and compare RME in subjects with OHS and a control group using an incremental load test and compare the RME of subjects with OHS in whom noninvasive ventilation (NIV) was and was not used.

METHODS

Forty subjects with OHS (divided according to body mass index [BMI] as group I: 30-40 kg/m²; and group II: ≥ 40 kg/m²) and 20 subjects with obesity (control group: 30-40 kg/m²) were included in the study. RME was evaluated using the incremental load test, and respiratory muscle strength (RMS) was evaluated using mouth pressure measurements. The 6-min walk test, Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), EQ-5D Health-Related Quality of Life Questionnaire (EQ-5D), and the Obesity and Weight-Loss Quality of Life Instrument (OWLQOL) were performed.

RESULTS

RME and RMS (%) in group I were lower than the control group (P = .001, P = .005, and P = .001, respectively). No significant difference was found between the 3 groups in terms of 6-min walk distance (6MWD) percentage predicted values (P = .98). RME in the NIV user group was higher than the non-user group (P = .006). ESS, total PSQI, and FSS scores in the control group were less than group I (P = .01, P = .009, and P = .005, respectively) and group II (P = .01, P < .001, and P < .001, respectively). The EQ-5D scores of the control group were higher than group II only (P = .005 and P = .005, respectively). There were no differences in OWLQOL between the groups (P = .053).

CONCLUSIONS

RME was low in subjects with OHS but higher in those who used NIV. The incremental load test could be performed easily and safely in a clinic setting.

AB0331 PULMONARY INVOLVEMENT IN A SINGLE CENTER COHORT OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

The prevalence of SLE pulmonary involvement varies depending on several factors, including diagnostic methods [1].

Objectives:

We aimed to determine the frequency of involvement with different diagnostic methods in a single center cohort.

Methods:

300 SLE patients were included. Chest x-ray (CXR), lung spirometry, carbonmonoxide diffusion test (DLCOc) and echocardiography were performed. High resolution thorax computed tomography (HRCT) was done for a definite diagnosis of interstitial lung disease (ILD) whilst diagram electromyography (EMG), ultrasonography (USG) and magnetic resonance imaging (MR) were utilized to diagnose shrinking lung syndrome (SLS).

Results:

The mean age and follow-up time were 43 and 11,5 years respectively. Of 300 patients, 16% had ILD, 6,7% had pulmonary hypertension (PHT), 3% had SLS, 0,3% had pulmonary infarction. At the start of the study, patients’ records showed that 4% had ILD, 5% PHT, 0,3% SLS and 0,3% pulmonary infarction. The median age, mean duration of disease and follow-up time were significantly higher and longer in patients with ILD compared to patients without (p<0.05). Forced expiratory volume (FEV1), forced vital capacity (FVC), DLCOc and total lung capacity (TLC) were significantly lower in patients with ILD and with SLS (p<0,001). Patients with ILD had significantly higher frequency of arthritis, serositis, Raynaud myositis and anti-Scl70 positivity. Avascular necrosis, diabetes and malignancy were significantly more frequent in those patients. All patients with suspected SLS undergone diagram EMG, USG and MR. Out of 10 suspected cases, in 6 EMG, in 5 USG and in 9 MR was compatible with SLS diagnosis. 5 patients had 3 of the diagnostic methods positive to diagnose SLS. Muscle atrophy and weakness, avascular necrosis were more frequent in this group of patients (p<0.05). There were more patients treated with mycophenolate mofetil (MMF) and cyclophosphamide in the SLS group whilst more with MMF in the ILD group. Significantly higher frequency of patients had stopped using hydroxychloroquine (HCQ) in the ILD group (p=0,04).

Conclusion:

Interstitial lung disease is common in patients with SLE and considerable number of patients have SLS [2]. Spirometry, DLCOc and CXR are simple but valuable to diagnose pulmonary involvement in SLE patients. Diaphragm MR, USG and EMG are complementary methods for definite diagnosis in SLS [2]. Considering the significant difference of prevalence between the start and the end of the study, one of the possibbilities is the underrecognition of SLE pulmonary disease due to its being part of a multisystemic presentation. Higher usage of immunosuppressives in these patients may support a multisystemic active disease. Although drug effect is another concern, it is hard to establish a causal relationship due to the study’s cross-sectional design. HCQ may have a role in ILD prevention.

References:

[1]Keane MP, Lynch JP. Pleuropulmonary manifestations of systemic lupus erythematosus. Thorax 2000;55:159-166.

[2]Singh R, Huang W, Menon Y, Espinoza LR. Shrinking lung syndrome in systemic lupus erythematosus and Sjogren’s syndrome. J Clin Rheumatol. 2002 Dec;8(6):340-5.

Table 1.

Spirometry; DLCO; diaphragm EMG, USG and MRI results of patients with SLS.

Patient/Age/Sex1/44/F2/57/F3/39/F4/38/M5/23/F6/60/F7/58/F8/37/F9/66/F10/28/FFEV1 (%)47655963676271537039FVC (%)56735962797072556237DLCO (%)45504465535547656245TLC (%)61716566786454636245USG deep inspiration (L)4,704,742,593,013,063,065,734,172,121,59USG deep inspiration (R)3,721,982,262,242,772,174,672,834,622,49USG diaphragm thickness (L)4,823,002,482,842,551,592,093,181,621,44USG diaphragm thickness R(R)1,231,041,841,802,191,311,791,972,081,63MR high sideRRRRRRRLLMR height difference4,926,192,872,641,672,451,730,950,78EMG resting AMP (R)0,20,30,60,50,60,40,10,80,90,7EMG resting LAT (R)76,47,166,786,154,7565,8EMG resting AMP (L)0,40,50,80,71,20,60,31,20,50,5EMG resting LAT (L)6,355,756,855,66,05664,355,26,15

Disclosure of Interests:

None declared

Diaphragmatic dysfunction at the first visit to a chest diseases outpatient clinic in 500 patients with amyotrophic lateral sclerosis

INTRODUCTION

In this study, we aimed to evaluate diaphragmatic dysfunction (DD) by using a practical approach in patients with amyotrophic lateral sclerosis (ALS) at the first visit to a chest diseases outpatient clinic.

METHODS

Patients with ALS seen in our outpatient clinic for the past 5 y and followed up for at least 1 y, were retrospectively evaluated. Having at least one of the following three criteria was accepted as DD: (a) paradoxical abdominal movement (PAM), (b) sitting-supine forced vital capacity (FVC) difference ≥ 20%, (c) sitting-supine arterial oxygen saturation measured by pulse oximetry (SpO₂ ) difference ≥ 4%. Respiratory symptoms, arterial blood gas analysis, sleep studies, noninvasive mechanical ventilation use, and mortality were recorded.

RESULTS

Five-hundred patients with ALS were included (female/male: 220/280, age: 58.9 ± 11.3 y). Of the patients, 22.8% had daytime hypercapnia. DD was observed in 55% of the patients (PAM in 112, sitting-supine FVC difference ≥ 20% in 50, and sitting-supine SpO₂ difference ≥ 4% in 113 patients). Of the patients with DD, 31.6% (n = 87) had no respiratory symptoms, 46.4% had FVC > 70% and 33.5% had FVC <50%. Nocturnal hypoxemia (sleep time spent with SpO₂  < 90% ≥30%) was present in 59.7%, and all patients with nocturnal hypoxemia had DD. Obstructive sleep apnea (8 severe, 14 moderate, 39 mild) was detected in 55% of the patients with polysomnography (n = 61) or polygraphy (n = 50). During follow-up, 52.2% of the patients died. Mean survival time was shorter in patients with DD (P < .001).

CONCLUSION

Paradoxical abdomimal movement (PAM), sitting-supine SpO₂ difference ≥ 4% and sitting-supine FVC difference ≥ 20% are indicators of DD, which should be routinely evaluated at every outpatient visit.

Are home sleep studies useful in diagnosing obstructive sleep apnea in children with down syndrome?

INTRODUCTION AND AIM

Obstructive sleep apnea syndrome (OSAS) is frequent in children with Down syndrome (DS) and polysomnography (PSG) is recommended for all children with DS. However PSG is not always available and alternative diagnostic methods are needed. The aim of the study was to evaluate the feasibility and validity of home polygraphy (HPG) in children with DS.

METHODS

A national DS association was contacted and children aged 6 to 18 years who accepted to participate were recruited. Otorhinolaryngologic evaluation, in-lab PSG and HPG were performed. OSAS was diagnosed by PSG with an apnea-hypopnea index (AHI) more than or equal to  1. OSAS severity was classified as moderate-to-severe if AHI was more than or equal to  5. Receiver operating characteristic curves were calculated for HPG using PSG as the gold standard.

RESULTS

Nineteen children (12 girls) completed the study. Median age was 11.3 years. Demographic and clinical characteristics were similar in children with and without OSAS. Eighty-nine percent of HPG studies were technically acceptable at the initial night and the success rate was 100% when two failed studies were repeated. PSG revealed OSAS in six (32%) children, two had mild and four had moderate-to-severe OSAS. All four patients with moderate-to-severe OSAS diagnosed with PSG have been diagnosed with the same severity on HPG. HPG had 100% sensitivity and 83% specificity when AHI ≥  3 was set as diagnostic criteria.

CONCLUSION

HPG is a feasible and reliable test of OSAS in children with DS and may be useful in diagnosis and treatment of patients with moderate-to-severe OSAS in this patient group.

Leptin and adiponectin levels in obstructive sleep apnea phenotypes

Objective: To examine the serum levels of leptin and adiponectin in different obstructive sleep apnea (OSA) phenotypes. Methods: Obese patients who were admitted to our sleep laboratory were included. All patients underwent spirometry, daytime arterial blood gas analysis, polysomnography and transthoracic echocardiography. Serum levels of adiponectin and leptin were recorded. Results: Analysis included 146 OSA patients (81 females, 65 males, age: 49.8 ± 10.7 years, body mass index: 40.3 ± 4.9 kg/m², 47.9% severe OSA, 42.5% severe obesity). Females had higher leptin and adiponectin levels (p < 0.001; p < 0.001, respectively). Leptin levels were higher in patients with severe obesity (p < 0.001). Severe OSA patients had lower leptin and adiponectin levels (p = 0.023; p = 0.035, respectively). Conclusion: Adipokine levels were different especially in OSA patients with severe obesity, female gender and severe OSA.

Comparison of arterial and venous blood gases in patients with obesity hypoventilation syndrome and neuromuscular disease

OBJECTIVES:

Obesity hypoventilation syndrome (OHS) and some neuromuscular diseases (NMD) present with hypercapnic respiratory failure. Arterial blood gas (ABG) analysis is important in the diagnosis, follow-up, and treatment response of these diseases. However, ABG sampling is difficult in these patients because of excessive subcutaneous fat tissue, muscle atrophy, or contracture. The aim of this study is to investigate the value of venous blood gas (VBG), which is an easier and less complicated method, among stable patients with OHS and NMD.

METHODS:

The study included stable OHS and NMD patients who had been previously diagnosed and followed up between March 2017 and May 2017 in the outpatient clinic. ABG was taken from all patients in room air, and peripheral VBG was taken within 5 min after ABG sampling.

RESULTS:

Thirty-six patients with OHS and 46 patients with NMD were included in the study. There was a moderate positive correlation between arterial and venous pH values for all patients (r_s = 0.590, P < 0.001). There were a strong and very strong positive correlations between arterial and venous pCO₂ and HCO₃ values (r_s = 0.725 and r_s = 0.934, respectively) (P < 0.001). There was no correlation between arterial and venous pO₂ and saturation values. There was an agreement in Bland–Altman method for the values of ABG and VBG (pH, pCO₂, and HCO₃).

CONCLUSIONS:

There was a correlation between ABG and VBG values (pH, pCO₂, and HCO₃). VBG parameters (pH, pCO₂, and HCO₃) can be used safely instead of ABG parameters which have many risks, during treatment and follow-up of patients with OHS and NMD.

Serum endocan levels in patients with stable COPD

Background

Endothelial cell specific molecule-1, also called as endocan, is a dermatan sulfate proteoglycan, which is expressed by endothelial cells in alveolar walls of the lung and kidney. High endocan levels are found associated with endothelial dysfunction and inflammation. We hypothesize that endocan level is also high in COPD due to systemic inflammation and endothelial dysfunction. We aimed to investigate the expression of endocan in patients with stable COPD.

Material and methods

The study included patients with COPD and control subjects. COPD patients were classified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 criteria. Demographics, body mass index, smoking history, and comorbidities were recorded. Endocan levels of COPD patients and controls were compared.

Results

Totally, 88 subjects (47 stable COPD patients, 41 controls) were evaluated. Endocan levels were significantly higher in COPD patients than control group (860.1±259.8 vs 647.3±316.9 pg/mL, P=0.001). There was no relationship between GOLD COPD categories and endocan levels. Also endocan levels were similar between COPD patients with or without hypoxemia.

Conclusion

Serum endocan level was significantly higher in patients with stable COPD. Further studies should be performed to better understand the relationship between endocan and COPD.

Sleep quality and quality of life in patients with moderate to very severe chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is highly associated with obstructive sleep apnea (OSA). Poor sleep quality is found to be related with decreased quality of life (QoL) in patients with COPD but no study assessed this relationship on the basis of nocturnal sleep parameters.

OBJECTIVES

The aim of this study is to explore the relationships between sleep quality, daytime sleepiness and QoL in patients suffering from moderate to very severe COPD with and without sleep apnea assessed objectively and to compare sleep quality, QoL and daytime sleepiness in patients suffering from COPD with and without sleep apnea.

METHODS

Fifty-one patients with stable moderate to very severe COPD (mean age, 59.8 ± 8.1 years) included in the study. The parameters of polygraphic sleep studies (Stardust II, Philips-Respironics) were noted. Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), The Modified Medical Research Council Dyspnea and SF-36 Health Quality Survey were performed.

RESULTS

The rate of OSA was 74.5% (Apnea-Hypopnea Index, >5). out of all the patients, 94% had poor sleep quality (PSQI, >5). Negative correlations were found between PSQI and physical role, social function and mental health of SF-36 subgroups (P < .05). There was no correlation between PSQI, ESS, SF-36, dyspnea and polygraphic parameters (P > .05). In the comparison of patients with or without OSA, the vitality of SF-36 subgroup was found lower in patients with OSA (P < .05).

CONCLUSIONS

In conclusion, irrespective of OSA, patients with COPD are suffering from poor sleep quality and poor sleep quality negatively affects the QoL. Also, COPD and OSA association causes worsened vitality in the terms of health-related QoL.

Fractional Exhaled Nitric Oxide Measurement in Pulmonary Hypertension: A Follow-Up Study

Pulmonary hypertension (PH) is a fatal disease although significant improvements in treatment are achieved. Easily implemented and noninvasive prognostic techniques are needed while following-up these patients. The aim was to investigate the role of fractional exhaled nitric oxide (FeNO) in follow-up for patients with PH. In this longitudinal study, patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH) who were seen in PH Outpatient Clinic, Istanbul Faculty of Medicine, Istanbul University, were enrolled in the study. Echocardiography, 6-minute walking test, brain natriuretic peptide, and FeNO measurements were performed, and World Health Organization functional class was evaluated to all patients at baseline, and third, and sixth months. Right-heart catheterization and pulmonary function tests at the time of diagnosis were recorded. The study comprised 31 patients (23 women, 8 men; mean age: 53.4 ± 17.1 years) with PAH (n = 19) and CTEPH (n = 12) and 80 healthy controls. Patients with PH had lower FeNO values than the control group (16.5 ppb vs 19.8 ppb; P < .05). Fractional exhaled nitric oxide values did not change during follow-up and did not correlate with other follow-up measures except tricuspid annular plane systolic excursion values. Fractional exhaled nitric oxide was higher in the idiopathic PAH subgroup at baseline and at third month than patients with PAH associated with other diseases. Fractional exhaled nitric oxide did not change in patients who had clinical deterioration. As a conclusion; Patients with PH had lower FeNO values than healthy controls, but FeNO did not change significantly during follow-up. Large-scale studies with prolonged follow-up periods are needed to understand the role of FeNO in the follow-up of the patients with PH.

An unusual radiographic finding in pulmonary parenchymal endometriosis: A case report

Thoracic endometriosis is an uncommon disorder. In most cases, the diagnosis is based on history alone and radiographic findings depend on the menstrual cycle. CT findings include ill-defined or well-defined opacities, nodular lesions, cavities, cystic changes and bullous formation. We report a case of pulmonary parenchymal endometriosis with an unusual radiographic finding.

Platelet Glycoprotein Ia 807c/T and 873g/A Polymorphisms in Patients With Venous Thromboembolism

Two silent polymorphisms (807C/T and 873G/A) within glycoprotein Ia (GPIa) gene have been implicated in increased risk of developing thrombosis and myocardial infarction in affected individuals. The aim of this study was to investigate the GPIa gene polymorphism in patients with venous thromboembolism (VTE). A multiplexed allele specific-polymerase chain reaction (AS-PCR)–based method was used to determine the GPIa 807T/873A allele frequency in 77 patients with VTE and 106 healthy controls. The allelic frequency for 807T/873A was 33% in the patient group and 38% in the control group. The allelic frequency for 807C/873G was 66% in the patient group and 62% in the control group. The genotypic frequencies were 8% for 807TT/873AA, 42% for 807CC/GG, and 50% for 807CT/GA in the patient group. In the control group, the frequencies were 12% for 807TT/873AA, 35% for 807CC/873GG, and 52% for 807CT/873GA. As a result, the glycoprotein Ia 807C/T and 873G/A dimorphisms were not shown as risk factors for VTE.

The role of an activity monitor in the objective evaluation of patients with pulmonary hypertension

INTRODUCTION

Patients with pulmonary hypertension (PH) show no symptoms at rest, but symptoms are triggered by physical activities.

OBJECTIVES

The primary aim of our study was to assess physical activity of patients with PH by using an activity monitor. The secondary aim was to evaluate the correlation between the activity monitor parameters and 6-min walk distance (6MWD), activity of daily living (ADL), quality of life, WHO functional class and PH classification.

METHODS

Thirty-eight patients with pulmonary arterial hypertension (PAH) and seven patients with chronic thromboembolic PH were included in the study. Physical activity was assessed using a SenseWear arm band. A 6-min walk test was performed. Daily living activities were assessed using the 'nottingham extended activity of daily living index' (NEADL). For quality of life assessments, 'Minnesota living with heart failure' (MLHF) and 'Short form-36' (SF-36) surveys were used.

RESULTS

Physical activity, exercise capacity, quality of life and contribution to ADL were lower in patients with PH. These data were associated with the 6MWD, quality of life and ADL index scores. We also found weak and moderate correlations between activity monitor data and SF-36 sub-group scores, MLHF and NEADL scores (P < 0.05). For the group with PAH, idiopathic PAH patients had more exercise capacity and total energy expenditure compared with patients with scleroderma-associated PAH.

CONCLUSION

Correlation between activity monitor data and 6MWD, most of SF-36 sub-group scores, MLHF scores and NEADL index scores suggest that activity monitor can be used in the evaluation of patients with PH.

Inspiratory Muscle Training in Late-Onset Pompe Disease: The Effects on Pulmonary Function Tests, Quality of Life, and Sleep Quality

INTRODUCTION

Late-onset Pompe disease (LOPD) is characterized by progressive skeletal and respiratory muscle weakness. Little is known about the effect of inspiratory muscle training (IMT) on pulmonary function in subjects with LOPD. The aim of the present study was to investigate the effect of an 8-week IMT program on pulmonary function tests, quality of life, and sleep quality in eight patients with LOPD who were receiving enzyme replacement therapy (ERT).

METHODS

Before and after the IMT program, spirometric measurements in sitting and supine positions, and measurements of maximum inspiratory and expiratory pressures, peak cough flow, quality of life (assessed using the Nottingham Health Profile), and sleep quality (assessed using the Pittsburgh sleep quality index) were performed.

RESULTS

A significant increase in maximum inspiratory pressure (cmH2O and % predicted) (median [interquartile range]: 30.0 cmH2O [21.5-48] versus 39 cmH2O [31.2-56.5] and 38.3 % [28.1-48.4] versus 50.5 % [37.7-54.9]) was observed after training (p = 0.01). There were no significant changes in the other pulmonary function measurements. With the exception of the social isolation subscore (p = 0.02), quality of life subscores did not change after IMT (p > 0.05). Sleep quality subscores and total scores were similar before and after IMT.

CONCLUSION

These results suggest that IMT has a positive effect on maximum inspiratory pressure in subjects with LOPD who are under ERT.

Spirometric obstruction and tobacco exposure among male Turkish nursing home residents

Spirometric obstruction is a prevalent problem in older adults and related to life-style risk factors. Symptoms related to chronic-obstructive-pulmonary-disease (COPD) are also prevalent symptoms with diverse etiologies - not limited to pulmonary obstruction. Older adults may have unrecognized airway obstruction due to functional limitations or symptoms mis-attributed to age/other co-morbidities. Therefore, spirometric obstruction may clinically be over/under diagnosed. Over last few decades, the burden of smoking-related diseases has increased in older adults. Additional evidence regarding older adults is required. We aimed to study frequency of spirometric obstruction, its over/under diagnosis and tobacco exposure in a group of male nursing-home residents. For spirometric obstruction diagnosis, two different thresholds [(fixed value: 0.70) versus (age-corrected value: 0.65 in residents >65 years of age)] were compared for better clinical practice. One hundred and three residents with 71.4 ± 6.3 years-of-age included. Spirometric obstruction prevalences were 39.8 and 29.1% with fixed and age-corrected FEV1/FVC thresholds, respectively. Age-corrected FEV1/FVC threshold underdiagnosed COPD in 1.9% while fixed threshold overdiagnosed spirometric obstruction in 8.7%. Active smokers were 64.1%, ex-smokers 23.3% and non-smokers 12.6%. Our study suggests high prevalences of spirometric obstruction and smoking in male nursing-home residents in Turkey. We suggest the use of age-corrected FEV1/FVC threshold practicing better than the use of fixed FEV1/FVC threshold in this patient group.

Does the 6-minute walk test predict nocturnal oxygen desaturation in patients with moderate to severe COPD?

Patients with chronic obstructive pulmonary disease (COPD) who have nocturnal oxygen desaturation (NOD) can be treated with nocturnal oxygen therapy (NOT) to avoid possible morbidity and mortality. Although there is no definite data recommending NOT alone, our aim is to evaluate the relationship between desaturation during the six-minute walk test (6MWT) and NOD in COPD. Fifty-five stable patients with COPD were enrolled in this study. The 6MWT and nocturnal oximetry were performed. Patients with comorbid diseases and respiratory failure were excluded. In total, 55 patients (49 males and 6 females, mean age: 65.8 ± 8.4 years) were analysed. Twenty-seven of the patients had moderate COPD and the remainder (n = 28) had severe COPD. Three patients (11%) with moderate COPD and 12 patients (42.9%) with severe COPD desaturated during 6MWT (p = 0.003). NOD was observed in five patients with severe COPD (17.9%). There were no patients with NOD in the moderate COPD group. Three (25%) of patients with severe COPD who desaturated during the 6MWT also had NOD. NOD was more common in patients with severe COPD and the patients with higher carbon dioxide levels (p = 0.02 and p = 0.001). Three patients (11%) with moderate COPD desaturated during the 6MWT; however they did not have NOD. Although the sample size in this study was too small to be conclusive, NOD was more common in desaturators during the 6MWT particularly in patients with severe COPD.

[Treatment of severe asthma: expert opinion]

Severe asthmatics account 10% of the all asthmatic population. Those asthmatics whose disease is inadequately controlled account for up to half of the cost for asthma, because they have more emergency room visits, more hospital admission and greater absenteeism from work. New therapeutic options were tried in those patients whose asthma was uncontrolled with standart high dose inhaled corticosteroid and long acting beta-2 agonsit combination therapy. In this paper taking into account the conditions of our country, current literature was reviewed and treatment options was discussed and graded recommendations are made for daily clinical practice in patients with severe treatment-refractory asthma.

Relation between hand grip strength, respiratory muscle strength and spirometric measures in male nursing home residents

Adverse-outcomes related to sarcopenia are mostly mentioned as physical disability. As the other skeletal muscles, respiratory muscles may also be affected by sarcopenia. Respiratory muscle strength is known to affect pulmonary functions. Therefore, we aimed to investigate the relations between extremity muscle strength, respiratory muscle strengths and spirometric measures in a group of male nursing home residents. Among a total of 104 male residents, residents with obstructive measures were excluded and final study population was composed of 62 residents. Mean age was 70.5 ± 6.7 years, body mass index: 27.7 ± 5.3 kg/m2 and dominant hand grip strength: 29.7 ± 6.5 kg. Hand grip strength was positively correlated with maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) (r = 0.35, p < 0.01 and r = 0.26, p < 0.05, respectively). In regression analysis, the only factor related to MIP was hand grip strength; among spirometric measures only parameter significantly related to grip strength was peak cough flow (PCF). The association of PCF with grip strength disappeared when MIP alone or "MIP and MEP" were included in the regression analysis. In the latter case, PCF was significantly associated only with MIP. We found peripheric muscle strength be associated with MIP and PCF but not with MEP or any other spirometric parameters. The relation between peripheral muscle strength and PCF was mediated by MIP. Our findings suggest that sarcopenia may affect inspiratory muscle strength earlier or more than the expiratory muscle strength. Sarcopenia may cause decrease in PCF in the elderly, which may stand for some common adverse respiratory complications.

Effects of simvastatin on bleomycin-induced pulmonary fibrosis in female rats

Statins reduce cholesterol levels by inhibiting 3-hydroxy-3-methylglutaryl coenzyme A reductase and have a major place in the treatment of atherosclerotic disease. Recent studies have shown anti-inflammatory properties of statins. The purpose of this study was to evaluate the anti-inflammatory effect of simvastatin on bleomycin (BLM)-induced pulmonary fibrosis in rats. A total of 31 female Sprague-Dawley rats were divided into four groups: (1) intratracheal (IT) phosphate-buffered saline (PBS) + intraperitoneal (IP) PBS (n=7); (2) IT BLM + IP PBS (n=8); (3) IT BLM + low dose (LD) simvastatin (1 mg/kg daily, n=8); (4) IT BLM + high dose (HD) simvastatin (5 mg/kg daily, n=8). Simvastatin was administered IP for 15 days, beginning 1 day prior to IT BLM. The effect of simvastatin on pulmonary fibrosis was studied by measurements of IL-13, PDGF, IFN-γ, TGF-p1 levels in bronchoalveolar lavage (BAL) fluid and lung tissue hydroxyproline (HPL) content and by histopathological examination (Ashcroft score). BLM caused significant change in BAL fluid cytokine levels and increased both HPL content and histopathological score (p<0.001 for all). While LD simvastatin had no effect on cytokine levels, HD significantly reduced IL-13 (15.12 ±7.08 pg/ml vs. 4.43±2.34 pg/mL; p<0.05) and TGF-β1 levels (269.25 ±65.42 pg/mL vs. 131.75±32.65 pg/mL; p<0.05). Neither HD nor LD simvastatin attenuated HPL content or Ashcroft score. In conclusion, this study showed that LD simvastatin had no effect on a BLM-induced pulmonary fibrosis model, while the high dose caused partial improvement in profibrotic cytokine levels.

Serum ghrelin and adiponectin levels are increased but serum leptin level is unchanged in low weight Chronic Obstructive Pulmonary Disease patients

BACKGROUND

Weight loss and muscle wasting are common features reported in COPD patients and they are all related with systemic inflammation. In this study, the relationship between pulmonary functions and inflammatory and metabolic parameters in low weight COPD patients were investigated.

METHODS

Fifty male COPD patients were grouped according to the Global Initiative for Chronic Obstructive Lung Disease criteria. Group 1: Mild-moderate COPD patients (n=18; with a mean age of 66.4 ± 9.2 yrs; body mass index (BMI):19.7 ± 1.5 kg/m(2)), group 2: Severe-very severe COPD patients (n=32; with a mean age of 65.9 ± 10.0 yrs; BMI:19.3 ± 1.6 kg/m(2)), group 3: Control group composed of healthy nonsmoking males (n=17; with a mean age of 50.2 ± 8.4 yrs; BMI:21.85 ± 1.5 kg/m(2)). Anthropometric parameters, serum levels of adiponectin (ApN), ghrelin, leptin, hsCRP, IL-6, IL-1β, IL-8, TNF-α and pulmonary functions were compared.

RESULTS

Adiponectin concentration was higher in group 1 (43.3 ± 28.6 ng/mL; p<0.05) and group 2 (59.9 ± 31.8 ng/mL; p<0.001) when compared with the control group (23.5 ± 13.6 ng/mL). Ghrelin concentrations were higher in COPD groups (1281.0 ± 1173.7 and 1840.0 ± 403.6 pg/mL; p<0.05) compared to the control subjects (554.0 ± 281.9 pg/mL). When the groups were compared, no significant difference was found for leptin, IL-1β, TNF-α, and IL-8. Interleukin-6 and hsCRP levels were higher in group 1 than in the control group. ApN was negatively correlated with BMI and FEV1. In all groups, FEV1 showed positive correlation with BMI, skinfold thicknesses, insulin and triglyceride; negative correlation with age, pack/years, HDL-Chol and ApN. Increased SHBG with decreased insulin level and HOMA-IR may indicate increased insulin sensitivity in COPD groups.

CONCLUSION

The anti-inflammatory effect of ApN and ghrelin is more evident in severe-very severe COPD patients.

Effects of respiratory muscle training on pulmonary functions in patients with slowly progressive neuromuscular disease: a randomized controlled trial

Objective:

To investigate the effects of inspiratory and expiratory muscle training on pulmonary functions in patients with slowly progressive neuromuscular disease.

Design:

Prospective randomized controlled double-blinded study.

Setting:

Chest diseases clinic of university hospital.

Subjects:

Twenty-six patients with slowly progressive neuromuscular disease followed for respiratory problems were included in the study. Patients were randomly divided into two groups; experimental ( n = 14; age 31.6 ±12.3 years) and sham ( n = 12; age 26.5 ±8.6 years) groups.

Methods:

Spirometry, peak cough flow, maximal inspiratory pressure, maximal expiratory pressure, and sniff nasal inspiratory pressure were measured before the eighth week of study, and subsequently at end of it. Respiratory muscle training was performed by inspiratory (Threshold Inspiratory Muscle Trainer) and expiratory (Threshold Positive Expiratory Pressure) threshold loading methods. Training intensities were increased according to maximal inspiratory and expiratory pressures in the experimental group, while the lowest loads were used for training in the sham group. Patients performed 15 minutes inspiratory muscle training and 15 minutes expiratory muscle training, twice a day, five days/week, for a total of eight weeks at home. Training intensity was adjusted in the training group once a week.

Results:

Maximal inspiratory and expiratory pressures (cmH2O, % predicted) (respectively p = 0.002, p = 0.003, p = 0.04, p = 0.03) and sniff nasal inspiratory pressure ( p = 0.04) were improved in the experimental group when compared with the sham group. However, there was no improvement in spirometric measurements when groups were compared ( p > 0.05).

Conclusions:

As a conclusion of our study, we found that respiratory muscle strength improved by inspiratory and expiratory muscle training in patients with slowly progressive neuromuscular disease.

Obstructive sleep apnea is common in patients with interstitial lung disease

PURPOSE

The incidence of obstructive sleep apnea (OSA) in interstitial lung disease (ILD) has been reported at different frequencies in several studies. The aims of our study were to evaluate the frequency of OSA in ILD and to analyze the relationship between polysomnography (PSG) findings and pulmonary function, disease severity, parenchymal involvement, and Epworth Sleepiness Scale (ESS) scores.

METHODS

ILD patients with parenchymal involvement were evaluated. The disease severity was assessed using an index consisting of body mass index (BMI), carbon monoxide diffusion capacity, the Modified Medical Research Council dyspnea scale, and the 6-min walking distance. All of the patients had lung function, chest X-ray, PSG, ESS scoring, and an upper airway examination. Patients with a BMI ≥ 30 or significant upper airway pathologies were excluded.

RESULTS

Of 62 patients, 50 patients comprised the study group (14 male, 36 female; mean age 54 ± 12.35 years, mean BMI 25.9 ± 3.44 kg/m(2)) with diagnoses of idiopathic pulmonary fibrosis (IPF; n = 17), stage II-III sarcoidosis (n = 15), or scleroderma (n = 18). The frequency of OSA was 68 %. The mean apnea-hypopnea index (AHI) was 11.4 ± 12.5. OSA was more common in IPF patients (p = 0.009). The frequency of rapid eye movement-related sleep apnea was 52.9 %. The frequency of OSA was higher in patients with a disease severity index ≥3 (p = 0.04). The oxygen desaturation index and the AHI were higher in patients with diffuse radiological involvement (p = 0.007 and p = 0.043, respectively).

CONCLUSIONS

OSA is common in ILD. PSG or at minimum nocturnal oximetry should be performed, particularly in patients with functionally and radiologically severe disease.

Anti-inflammatory and anti-fibrotic effects of sirolimus on bleomycin-induced pulmonary fibrosis in rats

PURPOSE

Pulmonary fibrosis is a devastating disease with a poor prognosis. Although the diagnosis and pathophysiology of this disease have been better characterized over the past few years, there is no effective therapy for the disease. The aim of this study was to evaluate the anti-inflammatory and anti-fibrotic effects of sirolimus (SRL), which is a potential anti-fibrotic agent, by using bleomycin (BLM)-induced pulmonary fibrosis model in rats.

METHODS

A single intra-tracheal injection of BLM (2.5 U/kg) was administered and sirolimus (2.5 mg/kg/day) was given orally, beginning either one day before (early SRL) or nine days after (late SRL) the BLM administration. The effect of SRL on fibrosis was studied by analysis of cytokine levels in BAL fluid, measurement of lung tissue hydroxyproline (HPL) content and histopathological examination.

RESULTS

Both early and late SRL administrations caused a decrease in the levels of IL-13, PDGF-A and TGF-β1 (p=0.001) and an increase in IFN-γ levels (p=0.001) in BAL fluid. Early and late SRL also caused a decrease in HPL content (p=0.001). Early sirolimus caused a significant decrease in fibrosis score (p=0.001), while late SRL did not.

CONCLUSION

Sirolimus was effective in BLM-induced pulmonary fibrosis model, especially in the early phases of the disease.

The Role of a Vibration Response Imaging Device in the Selection of Patients for Lung Resection Surgery

BACKGROUND: Simpler and radiation free alternatives have been researched to estimate postoperative lung functions. Objective of the study is to investigate the reliability of predicted postoperative (ppo) forced expiratory volume in 1 second (FEV₁) and carbon monoxide diffusion capacity (DLCO) calculated by vibration response imaging (VRI) to guide the selection of patients for lung resection surgery in comparison with quantitative perfusion scintigraphy (Q scan). METHODS: 35 candidates for lung resection were enrolled in the study for preoperative and postoperative evaluation of FEV₁ and DLCO. RESULTS: Totally 25 patients had preoperative tests. VRI measurements showed strong correlation with Q scan measurements of predicted postoperative (ppo) FEV₁% (r= .87, p<.001), ppo FEV₁(L) (r=.90, p<.001) and ppo DLCO% (r=.90, p<.001). There was a correlation between ppo FEV₁ (% and L) calculated by Q scan and postoperative actual FEV₁ (% and L) (r=.47, p<.05; r=.73, p<.001). There was no difference between VRI measurements of ppo FEV₁(% and L) and postoperative actual FEV₁ values. There was a correlation between ppo FEV₁ (% and L) calculated by VRI and postoperative actual FEV₁(% and L) (r= .52, p<.05; r= .79, p<.001). The mean differences between ppo and postoperative actual FEV₁ values was 49ml for VRI versus 230ml for Q scan. Both VRI and Q scan ppo DLCO% did not show agreement with postoperative actual DLCO%. CONCLUSIONS: VRI, which is a non-invasive, radiation free and simple test, may be valuable in the preoperative evaluation of lung resection surgery. It may be a good alternative to Q scan.

Sleep apnea in adult myotonic dystrophy patients who have no excessive daytime sleepiness

PURPOSE

Sleep apnea is common in myotonic dystrophy (MD) and may cause respiratory failure. Most of the sleep studies have been performed in patients with excessive daytime sleepiness (EDS), which is a characteristic and strong predictor of sleep apnea. Therefore, we investigated the prevalence of sleep apnea in adult MD patients who have no EDS.

MATERIALS AND METHODS

Epworth Sleepiness Scale was used to exclude EDS and a score over 10 was accepted as an indicator of EDS. Sleep studies of 17 adult MD patients with the Epworth sleepiness scale score < or =10 were retrospectively reviewed. Spirometry (n = 16) and daytime arterial blood gasses were used to evaluate the relationship with nocturnal parameters.

RESULTS

On admission to the outpatient chest clinic, seven patients had normal spirometry, and ten had daytime hypercapnia and/or hypoxemia. All but one had sleep apnea (apnea-hypopnea index > or =5 events/h of sleep; mild in five, moderate in seven, and severe in four). Hypopneas were more common than apneas (16.9 +/- 13.2 events/h vs. 4.6 +/- 4.1 events/h). Nocturnal desaturation episodes were very frequent (oxygen desaturation index, 19.7 +/- 20.3/h of sleep). Three patients had central sleep apnea and 13 had obstructive sleep apnea. Body mass index, spirometry parameters (FVC and FEV1) and arterial oxygen tension were moderately correlated with nocturnal oxygenation parameters. Apnea-hypopnea index showed moderate correlation with spirometry parameters (FVC and FEV1).

CONCLUSION

Sleep apnea and oxygen desaturations are very common in MD patients who report no excessive daytime sleepiness. Daytime lung function parameters are not sufficiently reliable for screening sleep apnea. Therefore, we recommend routine polysomnography in MD patients.

Isolated laryngo-tracheal amyloidosis presenting as a refractory asthma and longstanding hoarseness

Respiratory tract amyloidosis is characterized by deposition of amyloid fibril protein at any site along the respiratory tract ranging from the larynx to the pulmonary parenchyma. Usually, it is not associated with primary systemic amyloidosis. We report a case with isolated laryngotracheal amyloidosis, which is relatively a rare condition, together with a history of refractory asthma accompanied with longstanding hoarseness.

Risk of active tuberculosis in adult household contacts of smear-positive pulmonary tuberculosis cases

SETTING

Seven public tuberculosis (TB) dispensaries in Istanbul, Turkey.

OBJECTIVE

To investigate the risk of active TB among adult household contacts (age > or = 15 years) of newly diagnosed sputum smear-positive pulmonary TB (PTB) cases in Istanbul.

DESIGN

A retrospective analysis of adult household contacts of 1570 pulmonary TB cases registered at seven TB dispensaries in Istanbul between 1997 and 2000.

RESULTS

A total of 6188 household contacts (mean contact/index case: 3.9) were included in the study, of whom 4114 (67%) were aged > or = 15 years (mean contact/index case: 2.6); 3310 (80.5%) of these participated in a contact investigation. The mean duration of follow-up was 2.2 years (range 1-4 years); 222 active TB cases (rate 5.4%, 95%CI 5.2-5.6) were detected, 171 within the first year. The incidence of active TB was 2491/100 000 (3555/100 000 in the 15-34 year age group and 1195/100 000 in the > or = 35 year age group, P < 0.0001). Rates of active TB were highest in the 15-24 year (8.5%) and 25-34 year (6.5%) age groups.

CONCLUSION

The incidence of active TB among adult household contacts of sputum smear-positive PTB cases was high. This high incidence justifies the prescription of chemopropylaxis not only for children but also for all contacts, especially those aged between 15 and 34 years.

Comparison of three clinical scoring methods in patients with pulmonary thromboembolism

The clinical diagnosis is not reliable in pulmonary thromboembolism (PTE) because the symptoms are mostly nonspecific. Different clinical prediction rules for PTE have been described recently. These rules are used to aid clinicians in assigning a pre-test probability to patients with clinical signs and symptoms of disease. The aim of this study was to assess the clinical probability of PTE using three different models (Wells, Wicki and modified Hyers scores) and to find their power to determine PTE probability. Clinical probabilities of patients with PTE were determined with Wells, Wicki and modified Hyers scores. Cramer's, contingency coefficient (CC), Spearman's rho, Kendal's tau-b and kappa tests were used for statistical analysis. The study included 248 patients (119 male, 129 female; mean age= 57 +/- 16.7 years). Although 61.3% of the patients were assigned high clinical probability with modified Hyers score, 56% and 50% of them were assigned moderate clinical probability with Wicki and Wells scores, respectively. The correlations of the clinical probabilities was low according to kappa correlation test and moderate according to the Cramer's, CC, Spearman's rho and Kendal's tau-b tests among these three scores. In conclusion, modified Hyers score showed higher percentage of high probability compared to Wells and Wicki scoring systems and the best correlation was found between the modified Hyers and Wells scores.

Hereditary Thrombophilic Risk Factors and Venous Thromboembolism in Istanbul, Turkey: The Role in Different Clinical Manifestations of Venous Thromboembolism

The aim of this study was to investigate the hereditary thrombophilic risk factors in patients with venous thromboembolism (VTE) and whether these risk factors play a different role in patients with isolated pulmonary embolism (PE) as compared with patients with deep vein thrombosis (DVT) and patients with PE + DVT. The protein C (PC), protein S, antithrombin activities, homocysteine levels, and factor V Leiden (FVL) G1691A and prothrombin G20210A mutations were evaluated in 191 patients with VTE and 191 controls. The prevalence of FVL and PC deficiency were higher in patients ( P = .003 and P = .02, respectively). There was no significant difference for the other risk factors. The combination of thrombophilic risk factors was significantly higher in patients with DVT + PE as compared with patients with isolated PE or DVT ( P = .04). In conclusion, the most important hereditary risk factors for VTE in this study were the FVL mutation and PC deficiency.

Disseminated alveolar echinococcosis mimicking a metastatic malignancy

Alveolar echinococcosis, which is caused by Echinococcus multilocularis, is a very aggressive and potentially fatal infestation which always affects the liver primarily and metastasizes to any part of the body. Imaging studies are usually highly suspicious of carcinoma or sarcoma, and biopsy may provide the first indication of infection. We report a case of disseminated alveolar echinococcosis with liver, lung, and bone involvement mimicking a metastatic malignancy.

[A case of heparin induced thrombocytopenia treated with lepirudin infusion: case report]

Heparin induced thrombocytopenia (HIT) is a life-threatening complication that can be seen in the course of heparin treatment. The syndrome is much likely to be seen during treatment with standard heparin but it can also be seen due to low molecular weight heparins. In this article, we presented a case of HIT who was given low molecular weight heparin for prophylaxis that developed massive pulmonary thromboembolism. The patient was successfully treated with lepirudin infusion and no complications due to treatment was seen.

Hashimoto thyroiditis and obstructive sleep apnea syndrome: is there any relation between them?

Hashimoto thyroiditis (HT), which is an autoimmune disease of thyroid gland, has been declared to present with concomitant several systemic diseases. In this study, the coexistence of the Hashimoto disease with the sleep apnea syndrome has been examined. Seven female patients (33-66 year of age) with Hashimoto thyroiditis were evaluated for sleep apnea syndrome. The diagnosis of Hashimoto disease was based on the high titers of anti-thyroid antibodies and histological findings. None of the patients had any complaints of sleep disturbances. Seven healthy subjects with similar age and sex characteristics were taken as the control group. All the patients and the control subjects were undertaken a full polysomnography (PSG). Five patients with HT showed the characteristics of obstructive sleep apnea syndrome (one severe, one moderate and three mild OSAS), whereas no sleep breathing disturbance was found in the control group. These findings suggest that sleep related breathing problems may develop in the patients with autoimmune thyroiditis even if they are euthyroid.

Clinical and radiographic features of pulmonary tuberculosis in non-AIDS immunocompromised patients

SETTING

Department of Chest Diseases, Istanbul Faculty of Medicine, Istanbul University.

OBJECTIVE

To determine the clinical and radiographic presentation of pulmonary tuberculosis in non-AIDS immunocompromised patients (ICP).

DESIGN

A retrospective review of medical records of 143 patients (63 immunocompromised patients and 80 immunocompetent patients) with pulmonary tuberculosis from 1992 to 2001.

RESULTS

In ICPs, fever was more frequently observed (84.1% vs. 40%, P = 0.0000002), tuberculosis was more frequently disseminated (23.8 vs. 3.8%, P = 0.0008), and lung infiltrations were more often lobar or segmental consolidation (20.6% vs. 0%, P = 0.00007) and miliary lesions (17.5 vs. 3.8%, P = 0.014) than in the control patients. Hilar and/or mediastinal adenopathy was also more frequently documented in ICPs (14.3% vs. 2.5%, P = 0.01).

CONCLUSION

Fever, atypical chest radiograph and disseminated disease are common findings of pulmonary tuberculosis in ICPs.

Should computed chest tomography be recommended in the medical certification of professional divers? A report of three cases with pulmonary air cysts

Pulmonary barotrauma (PBT) is a recognised risk of compressed gas diving. Any reason that causes air trapping in the lung during ascent may cause PBT by increasing intrapulmonary pressure. Chest x ray examination is mandatory for medical certification of the professional divers in many countries, but pulmonary air trapping lesions such as an air cyst in the lungs cannot always be detected by plain chest x ray examination. Computed tomography (CT) is a reliable, but expensive measure for detecting pulmonary abnormalities in divers. Three cases with pulmonary air cysts are reported in which air cysts were invisible on the x ray pictures, but well defined by CT. It is impractical and not cost effective to perform CT for medical certification of all divers, but it can be an option to recommend CT once during the initial examination of the candidates for professional diving, especially if there is a history of predisposing factors, such as smoking or pulmonary infections.

Evaluation of undergraduate training on tuberculosis at Istanbul Medical School

SETTING

Undergraduate training on tuberculosis at Istanbul Medical School.

OBJECTIVE

To assess whether tuberculosis-related questions asked in chest medicine examinations comply with the World Health Organization's (WHO) learning objectives for tuberculosis training, and to investigate students' skills in interpreting radiology and smears with respect to tuberculosis.

DESIGN

Tuberculosis questions set for 4th year medical students (n = 838) were compared with WHO objectives (n = 23): 122 students were each asked to interpret 10 chest X-rays which had been read by three experts as 'typical tuberculosis lesions', 'normal' or 'non-tuberculosis lesions'; 114 students were also each given five smears which had been interpreted by an expert as 'negative' or 'positive' with respect to acid-fast-bacilli (AFB), and were asked to interpret them.

RESULTS

Questions covered only nine of the WHO objectives. Among 117 types of questions, 91 (77.8%) were about clinical-radiological findings, treatment and drugs; 334 (65.1%) of 513 X-rays with typical tuberculosis lesions, 77 (21.1%) of 364 normal X-rays and 87 (25.4%) of 343 X-rays with non-tuberculosis lesions were identified as tuberculosis (kappa 0.45). Of 369 AFB-positive smears, 149 (40.4%) were evaluated as false negative, and of 185 AFB-negative smears, 48 (25.9%) were evaluated as false positive (kappa 0.49).

CONCLUSION

Examination questions set on tuberculosis at Istanbul Medical School do not adequately reflect WHO learning objectives. Students' skills in interpreting radiology and smears suggest that their practical training on tuberculosis is insufficient.