Prevalence of Thromboembolic Disease IncludingSuperior Vena Cava and Brachiocephalic Veins

Thrombosis of the brachiocephalic veins or superior vena cava (SVC) is rare. This study was conducted to determine the prevalence and characteristics of thrombosis of brachiocephalic veins and SVC, and its association with symptomatic pulmonary embolism (PE). The prevalence of thrombosis involving the brachiocephalic veins and SVC was evaluated retrospectively at a university hospital during the 3-year period. Patients were identified by hospital records and review of computer-generated lists of of all venograms, contrast-enhanced chest computed tomography, and magnetic resonance angiograms of the upper extremity and SVC. Thrombosis of the brachiocephalic veins and SVC was diagnosed in 33 (0.03%) of 100,942 patients of all ages [(32 of 70,751 adult patients≥ 20 years; 0.04%)]. Twenty-three (70%) patients initially had secondary thrombosis with multiple risk factors: associated with malignancy in 14 (42%) patients, chronic disorders in 13 (39%) patients, central venous lines (CVL) and peripheral venous lines (PVL) in 9 (27%) patients, and thrombophilia in 10 (38%) of 26 patients. Swelling of the arm, head, and neck was present in 32 (97%) patients. Symptomatic PE developed before thrombosis being treated in 12 (36%) patients. All patients except eight (three, thrombolytic; five, thrombectomy) received anticoagulant therapy. Thrombosis of the SVC and brachiocephalic veins is an uncommon but serious complication in patients with malignancy, chronic disorders, CVL, PVL, and thrombophilia. Because it is important clinical problem with frequent PE, the patients with appropriate clinical findings should be diagnosed early with imaging tests and treated with anticoagulant drugs.

Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease

Background

Invasive pulmonary aspergillosis (IPA) is an infection often occurring in neutropenic patients and has high mortality rates. In recent years, it has been reported that the incidence of IPA has also increased in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study is to investigate the clinical and demographic characteristics and treatment responses of IPA in patients with COPD.

Methods

Seventy-one patients with a positive culture of Aspergillus from lower respiratory tract samples were examined retrospectively. Eleven (15.4%) of these patients, affected with grade 3 or 4 COPD, had IPA.

Results

Aspergillus hyphae were detected in lung biopsy in three (27.3%) out of 11 patients and defined as proven IPA; a pathological sample was not taken in the other eight (72.7%) patients, and these were defined as probable IPA. Aspergillus isolates were identified as six cases of Aspergillusfumigatus and three of Aspergillusniger in nine patients, while two isolates were not identified at species level. While five patients required intensive care unit admission, four of them received mechanical ventilation. The most common finding on chest X-ray and computed tomography (CT) (respectively 63.6%, 72.7%) was infiltration. Amphotericin B was the initial drug of choice in all patients and five patients were discharged with oral voriconazole after amphotericin B therapy. Six patients (54.5%) died before treatment was completed.

Conclusions

IPA should be taken into account in the differential diagnosis particularly in patients with severe and very severe COPD presenting with dyspnea exacerbation, poor clinical status, and a new pulmonary infiltrate under treatment with broad-spectrum antibiotics and steroids.

Invasive pulmonary aspergillosis in patients with chronic obstructive pulmonary disease

Background: Invasive pulmonary aspergillosis (IPA) is an infection often occurring in neutropenic patients and has high mortality rates. In recent years, it has been reported that the incidence of IPA has also increased in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study is to investigate the clinical and demographic characteristics and treatment responses of IPA in patients with COPD. Methods: Seventy-one patients with a positive culture of Aspergillus from lower respiratory tract samples were examined retrospectively. Eleven (15.4%) of these patients, affected with grade 3 or 4 COPD, had IPA. Results: Aspergillus hyphae were detected in lung biopsy in three (27.3%) out of 11 patients and defined as proven IPA; a pathological sample was not taken in the other eight (72.7%) patients, and these were defined as probable IPA. Aspergillus isolates were identified as six cases of Aspergillusfumigatus and three of Aspergillusniger in nine patients, while two isolates were not identified at species level. While five patients required intensive care unit admission, four of them received mechanical ventilation. The most common finding on chest X-ray and computed tomography (CT) (respectively 63.6%, 72.7%) was infiltration. Amphotericin B was the initial drug of choice in all patients and five patients were discharged with oral voriconazole after amphotericin B therapy. Six patients (54.5%) died before treatment was completed. Conclusions: IPA should be taken into account in the differential diagnosis particularly in patients with severe and very severe COPD presenting with dyspnea exacerbation, poor clinical status, and a new pulmonary infiltrate under treatment with broad-spectrum antibiotics and steroids.

Gluteal abscess: An unusual complication of Bacille Calmette-Guérin

Bacille Calmette-Guerin (BCG) has been used extensively as a vaccine against human tuberculosis. Herein, we describe gluteal tuberculosis abscess due to inadvertently injected BCG a patient with bladder cancer.

Obstructive sleep apnea syndrome is related to the progression of chronic kidney disease

BACKGROUND AND AIM

Obstructive sleep apnea syndrome (OSAS) is an independent risk factor for the development of cardiovascular events and hypertension. The possible causes are oxygen desaturation due to hypopnea, increased cytokine levels and insulin resistance. All these risk factors also have a role in the progression of chronic kidney disease (CKD). The aim of this study was to determine the relationship between OSAS and the severity of CKD.

MATERIALS AND METHODS

We retrospectively evaluated the medical records of 175 subjects who were admitted for the polysomnography study. OSAS was diagnosed by polysomnography if Apnea-Hypopnea Index (AHI) > 5 and glomerular filtration rate (GFR) was calculated with Cockcroft-Gault formula. According to AHI, individuals with AHI < 5 were recruited as group 1 (OSAS negative group), those with AHI = 5-15 group 2 (mild OSAS group), those with AHI = 15-30 group 3 (moderate OSAS group), and those with AHI > 30 group 4 (severe OSAS group).

RESULTS

Of the subjects, 117 (67%) were men, 58 (33%) were women and the mean age was 54.0 ± 12.1 years. There were 28 (14.3%), 18 (10.3%), 35 (20.0%) and 97 (55.4%) patients in groups 1, 2, 3 and 4 respectively. The prevalence of diabetes mellitus and hypertension and body mass index was significantly higher in severe OSAS group (P < 0.05). A significant decrease in GFR was detected when the severity of OSAS increased (group 1 = 50.0 ± 11.8, group 2 = 44.8 ± 15.9, group 3 = 40.8 ± 14.7, group 4 = 38.8 ± 16.0; P for trend < 0.001).

CONCLUSION

In the light of the present study, we speculate that OSAS is an independent risk factor for the progression of chronic kidney disease, which is a growing health problem. Further randomized-multicenter prospective studies are warranted to evaluate this relationship.

Leptin levels in various manifestations of pulmonary tuberculosis

BACKGROUND

Proinflammatory cytokines are prime candidates as causative agents of the metabolic changes that eventually result in tuberculosis-associated weight loss. Microbial products and cytokines such as TNF and IL-1 increase leptin expression dose dependently in adipose tissue. Leptin plays an important role in cellular immunity.

OBJECTIVES

In this study, we investigated serum leptin and TNF-alpha levels before and after antituberculosis therapy in patients with active pulmonary tuberculosis (TB).

METHODS

Twenty five in patients with active pulmonary TB and 18 healthy controls participated in the study. Leptin and TNF-alpha levels were measured before treatment and six months after the treatment and they were compared with the control group. Body mass index (BMI) and chest X-rays before and after the treatment were also evaluated.

RESULTS

The leptin levels before and after the treatment were 1.66+/-1.68 ng/mL and 3.26+/-3.81 ng/mL, respectively. The leptin levels of tuberculous patients were significant than in healthy patients (P < .05). The BMI was 19.36+/-2.55 kg/m2 before the treatment and 22.87+/-3.13 kg/m2 after the treatment. The TNF-alpha level was 23.19+/-12.78 pg/mL before the treatment and 15.95+/-6.58 pg/mL after the treatment. There was no correlation between leptin and TNF-alpha levels. Leptin levels were low in patients who had sequela lesion on chest radiographs.

CONCLUSION

Leptin levels are suppressed in tuberculous patients and low leptin levels may contribute to increased susceptibility to infection and recovery with sequela lesions.

Bronchiolitis obliterans Organizing Pneumonia

BACKGROUND

Bronchiolitis obliterans organizing pneumonia (BOOP) may be classified as cryptogenic (idiopathic) and secondary. There are no clear clinical and radiological features distinguishing between idiopathic and secondary BOOP.

OBJECTIVES

To analyze the etiologic factors, clinical and radiological features, diagnostic approach and response to therapy at onset and outcome in subjects with BOOP.

METHODS

The medical files of Erciyes University Hospital from 1995 to 2003 were retrospectively reviewed. Patients with biopsy-proven BOOP were selected for evaluation. The etiology and initial features of BOOP, treatment, resolution, relapse, and survival were obtained from medical records, and a follow-up patient questionnaire.

RESULTS

We have diagnosed 26 cases (13 males /13 females) with BOOP syndrome (mean age 54 +/- 15 years, range 14-93). More than half the patients (58%) were classified as idiopathic BOOP. Patients presented with cough (92%), dyspnea (70%), pleuritic chest pain, hemoptysis and fever (50%). The biopsy specimens had been obtained by transbronchial and/or transthoracic lung biopsy in 18 cases (69%). At radiological evaluation, there were bilateral patchy alveolar and/or interstitial infiltrates in 16 patients (62%), and solitary pneumonic involvement in 10 patients (38%). Three patients recovered spontaneously, 5 remained cured after resection of the focal lesion. Corticosteroid therapy was given in 17 patients (65%). Apart from four patients who died (death was attributable to BOOP in only 1 patient) and three patients who relapsed, the prognosis was good in all patients.

CONCLUSIONS

The etiology of BOOP is usually idiopathic. We observed that hemoptysis and pleuritic chest pain were a relatively frequent symptom in BOOP in the present series, in contrast to previous observations. The diversity of radiological and clinical presentations including hemotysis and pleuritic chest pain should prompt consideration of the diagnosis in patients with persisting pulmonary symptoms and radiological findings.

Ifosfamide, mesna, and interferon-alpha2A combination chemoimmunotherapy in malignant mesothelioma: results of a single center in central anatolia

Our aim was to determine the efficacy of ifosfamide, mesna, and interferon alpha combination therapy in malignant mesothelioma (MM) patients. Fourty-two patients (39 evaluable) with histologically proven MM were enrolled into this study from January 1999 to October 2002. The drug schedule consisted of a combination of ifosfamide, 3000 mg/m2 1-3 d intravenous infusion (iv), the uroprotective agent mesna, 3000 mg/m2 1-3 d iv every 3 wk, and interferon alpha2a, 4.5 MU subcutaneously (sc) 3 d/wk for 6 mo as first-line chemotherapy. Overall, 140 cycles were administered to the 39 patients (median, 3.5 cycles; range, 1 to 6 cycles). Among the 39 patients, 8 partial remissions (PR) (21%) were observed. Thirteen patients (33%) had stable disease for at least 8 wk and 18 (46%) had progressive disease. Overall survival (OAS) and progression free survival (PFS) for all patients were 10.0 +/- 2.9 mo (95%CI 4.3-15.7) and 5.0 +/- 1.9 mo (95%CI 1.38-8.62), respectively. One and two year survival rates were calculated as 39% and 5%, respectively. All of the PR patients had the epithelial type of MM. Their survival time was 21.0 +/- 5.7 mo (95% CI 9.9-32.1) and significantly longer than that of nonresponders (p=0.0061). The toxicity of the drug combination was mild and well tolerated. There were no treatment-related deaths. Grade 3-4 neutropenia and febrile neutropenia were seen in 10 patients (26%) and 3 patients (8%), respectively. Chemotherapy was stopped in three patients because of renal function deficiency. One of these patients who had peritoneal MM required hemodialysis. In conclusion, this combination therapy showed encouraging antitumor activity with modest toxicity.

Preliminary Results of a Phase II Study of Weekly Paclitaxel (PTX) and Carboplatin (CBDCA) Administered Concurrently With Thoracic Radiation Therapy (TRT) Followed by Consolidation Chemotherapy With PTX/CBDCA for Stage III Unresectable Non-Small-Cell Lung Cancer (NSCLC)

Concurrent chemoradiotherapy plays an important role in the treatment of unresectable NSCLC. This phase II study was conducted to evaluate the efficacy and toxicity of paclitaxel (PTX) and carboplatin (CBDCA) at a recommended dose, based on other previous phase I studies. Twenty-two unresectable stage III NSCLC patients participated in this trial. Of those 22 patients, 19 were evaluable, with a median age of 57 (with ages ranging between 42 and 74), in stages IIIA/IIIB: 6/13. Every patient displayed adequate organ functions. Treatment consisted of a 1-hour i.v. infusion of 50 mg/m2 of PTX followed by a half-hour infusion of CBDCA AUC 2 administered weekly concurrently with radiation treatment, every first day of those weeks in which the patient underwent radiotherapy. Concurrent thoracic radiation therapy was performed in daily doses of 2 Gy to a total dose of 66 Gy over a period of 6.5 weeks. After completion of chemoradiotherapy, consolidation chemotherapy was administered via a 3-hour i.v. infusion of 175 mg/2 PTX on days 1 and 22, in combination with a 1-hour i.v. infusion of CBDCA AUC 6 on days 1 and 22, q 4 weeks for 4 cycles. The overall response rate was 78.9% (95% CI: 62-87.7) with 5 CR (26.3%), 10 PR (52.6%), 2 SD (15.8%), and 1 PD (5.3%). The median survival rate of the patients was 13.9 months, and the 1-year survival rate was 65.1%. Toxicity was moderate: grade 2 neutropenia was seen in 8, and grade 3 neutropenia in 5 patients. Grade 2 thrombocytopenia was seen in 3 patients, and grade 3 thrombocytopenia was not observed. Nonhematologic toxicities were moderate: esophagitis was the most common, and significant toxicity was noted in this study (89.4%). Grade 1 asthenia/fatigue was observed in 5, and grade 2 asthenia/fatigue in 3 patients; furthermore, grade 1 peripheral neuropathy was seen in 4 of the cases and grade 2 peripheral neuropathy in 3 of the cases. Concurrent chemoradiotherapy with weekly PTX/CBDCA, followed by consolidation chemotherapy with the same regimen in patients with stage III unresectable NSCLC is feasible and well tolerated.

Evaluation of Malignant Mesothelioma in Central Anatolia: A Study of 67 Cases

BACKROUND:Malignant mesothelioma (MM) is a fatal neoplasm which frequently results from exposure to asbestos or erionite.

METHOD:Sixty-seven patients with MM were seen between 1990 and 2001. Their clinical and radiological features, as well as the therapy, were retrospectively evaluated.

RESULTS:In 51 patients (76.1%), the MM was confined to the pleura, in 14 patients it was exclusively peritoneal and in two patients, it involved both areas. Of the 67 cases, 35 (52.2%) were women. The mean (± SD) age for all cases was 57.6±11.5 years. Dyspnea (67.2%), cough (55.2%) and chest pain (50.7%) were the most frequent symptoms of onset. Pleural effusion (92.4%) was the most common chest x-ray finding, whereas pleural effusion (60.8%), pleural nodules (34.7%) and pleural thickening (34.7%) were the most common computed tomography findings in pleural MM patients. The histological subtypes of MM were determined as epithelial in 60 patients (89.5%), sarcomatous in four patients (5.9%) and mixed in three patients (4.4%). Although 50.7% and 25.4% of the cases were exposed to erionite and asbestos, respectively, 23.9% of the cases recalled no exposure to asbestos or erionite. Exposures were environmental as opposed to occupational. Thirty-five patients (52.2%) were administered chemotherapy, and follow-up data were available for 22 patients. For these patients, the two-year survival rate was 22% and the two-year progression-free interval was 15.7%. There were no differences between patients with asbestos and erionite exposure.

CONCLUSION:MM should be considered when exudative pleural effusion is detected in a patient who has been exposed to asbestos or erionite. MM is a major public health problem in parts of Turkey and compulsory environmental control of fibrous mineral should be considered.

Chronic pulmonary disease in rural women exposed to biomass fumes

INTRODUCTION

Biomass (organic) fuels cause indoor air pollution when used inside dwellings. We evaluated the frequencies of chronic obstructive pulmonary disease (COPD) and chronic bronchitis (CB) among rural women using biomass fuels for heating and cooking and compared them to women living in urban areas where such fuels are not used.

METHODS

From electoral lists we randomly selected 242 women living in rural areas near Kayseri, Turkey and 102 women living in apartments in the city having central heating and cooking with fuels other than biomass ones. Using a translated version of the American Thoracic Society questionnaire, with additional questions from the British Medical Research Council questionnaire, trained interviewers conducted personal interviews. They also collected information on fuels used for cooking and heating. All study subjects underwent a physical examination and measurement of pulmonary function.

RESULTS

We found that rural women were younger than urban women (mean age [and standard deviation], 40.5 [14.1] yr v. 43.6 [11.9] yr). More urban than rural women were current (14.7% v. 4.5%, p < 0.001) or past (11.8% v. 1.2%, p < 0.001) smokers. CB was more prevalent among rural women than urban women (20.7% v. 10.8%, p < 0.03). Similarly, COPD was more prevalent in rural women (12.4% v. 3.9%, p < 0.05). Although the pulmonary function tests were within normal limits, FEV, values in rural women were found to be relatively low compared with those of urban women (p < 0.05).

INTERPRETATION

Rural women exposed to biomass fumes are more likely to suffer from CB and COPD than urban women even though the prevalence of smoking is higher among the latter group.

Correlation of serum tumor necrosis factor-alpha, interleukin-4 and soluble interleukin-2 receptor levels with radiologic and clinical manifestations in active pulmonary tuberculosis

The precise clinical manifestations of tuberculosis are likely to result from a complex interaction between the host and the pathogen. We took serum samples from a group of patients with a variety of clinical and radiological stages of pulmonary tuberculosis in order to characterize tumor necrosis factor-alpha (TNF-alpha), interleukin-4 (IL-4) and soluble interleukin-2 receptor (sIL-2R) response. We further evaluated whether the levels of TNF-alpha, IL-4 and soluble IL-2R are related with each other, and also evaluated the levels of TNF-alpha, IL-4 and sIL-2R after anti-tuberculosis therapy and relation with radiologic scores. Forty-three inpatients with active pulmonary tuberculosis and 19 healthy controls participated in the study. Patients were divided into four categories radiologically on chest X-ray (minimal, moderate-advanced, far-advanced and with miliary infiltration). Concentrations of TNF-alpha (20.9+/-10/15.4+/-8 pg/ml) and sIL-2R (2569+/-842/1444+/-514 pg/ml) were statistically different between patients and controls (p=0.02 and p=0.0001, respectively). Before chemotherapy there was a positive correlation between TNF-alpha and sIL-2R (r=0.34), but there was no correlation between IL-4 and TNF-alpha, and between IL-4 and sIL-2R (r=-0.23 and r=-0.22). The TNF-alpha level was not statistically different in four groups before and after chemotherapy. Results of this study provided some evidence confirming the previously reported role of TNF-alpha, IL-4 and sIL 2R in the control of tuberculosis, but these cytokines were not found related with disease severity.

Antituberculosis drug resistance patterns in two regions of Turkey: a retrospective analysis

BACKGROUND

The emergence of Mycobacterium tuberculosis strains resistant to antituberculosis agents has recently received increased attention owing largely to the dramatic outbreaks of multi drug resistance tuberculosis (MDR-TB).

METHODS

Patients residing in Zonguldak and Kayseri provinces of Turkey with, pulmonary tuberculosis diagnosed between 1972 and 1999 were retrospectively identified. Drug susceptibility tests had been performed for isoniazid (INH), rifampin (RIF), streptomycin (SM), ethambutol (EMB) and thiacetasone (TH) after isolation by using the resistance proportion method.

RESULTS

Total 3718 patients were retrospectively studied. In 1972-1981, resistance rates for to SM and INH were found to be 14.8% and 9.8% respectively (n: 2172). In 1982-1991 period, resistance rates for INH, SM, RIF, EMB and TH were 14.2%, 14.4%, 10.5%, 2.7% and 2.9% (n: 683), while in 1992-1999 period 14.4%, 21.1%, 10.6%, 2.4% and 3.7% respectively (n: 863). Resistance rates were highest for SM and INH in three periods. MDR-TB patients constituted 7.3% and 6.6% of 1982-1991 and 1992-1999 periods (p > 0.05).

CONCLUSION

This study demonstrates the importance of resistance rates for TB. Continued surveillance and immediate therapeutic decisions should be undertaken in order to prevent the dissemination of such resistant strains.

Impaired lung epithelial permeability in hepatitis C virus antibody positive patients detected by 99mTc-DTPA aerosol scintigraphy

Chronic hepatitis C virus (HCV) infection has been recently identified as an aetiological agent in idiopathic pulmonary fibrosis. The present study was designed to determine the pulmonary clearance rate of 99mTc-diethylenetriaminepentaacetic acid (99mTc-DTPA) in asymptomatic HCV antibody positive (HCV Ab+) patients and the role of 99mTc-DTPA aerosol scintigraphy in the early detection of lung involvement. Twenty-six non-smoker HCV Ab+ and HCV-RNA (+) patients (20 female, six male; aged 43+/-11 years), with no clinical pulmonary symptoms, and normal radiological findings, were studied. Thirty-one healthy non-smoker volunteers (24 female, seven male; aged 40+/-10 years) were taken as a control group. 99mTc-DTPA aerosol inhalation scintigraphy and pulmonary function tests were performed in all patients and in controls. On the basis of the scintigrams the percentage decline in activity per minute (Kep) was evaluated, which represented an accurate parameter of lung membrane permeability. The mean Kep values of healthy controls (0.78+/-0.13 for left lung, 0.79+/-0.14 for right lung) were significantly lower than HCV Ab+ patients (1.10+/-0.31 for left lung, 1.11+/-0.34 for right lung, P<0.001). But no significant change was observed in PFT (P>0.05). We conclude that subclinical alveolitis and/or interstitial lung disease may be present in patients with HCV Ab+, since it is known that an increase in the epithelial permeability of the lung is an early manifestation of interstitial disease.