Understanding the Gaps in the Reporting of COPD Exacerbations by Patients: A Review

Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with loss of lung function, poor quality of life, loss of exercise capacity, risk of serious cardiovascular events, hospitalization, and death. However, patients underreport exacerbations, and evidence suggests that unreported exacerbations have similar negative health implications for patients as those that are reported. Whilst there is guidance for physicians to identify patients who are at risk of exacerbations, they do not help patients recognise and report them. Newly developed tools, such as the COPD Exacerbation Recognition Tool (CERT) have been designed to achieve this objective. This review focuses on the underreporting of COPD exacerbations by patients, the factors associated with this, the consequences of underreporting, and potential solutions.

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.

An Alpha-1 Antitrypsin Deficiency Screening Study in Patients with Chronic Obstructive Pulmonary Disease, Bronchiectasis, or Asthma in Turkey

Purpose

Alpha-1 antitrypsin deficiency (AATD) is a rare hereditary condition characterized by decreased serum alpha-1 antitrypsin (AAT) levels. We aim to identify AATD in patients with chronic obstructive pulmonary disease (COPD), bronchiectasis, or asthma and to report the frequency of AAT variants in Turkey.

Patients and Methods

This non-interventional, multicenter, prospective study was conducted between October 2021 and June 2022. Adult patients with COPD, bronchiectasis, asthma, liver symptoms, or family members with AATD were included. Demographic and clinical characteristics, pulmonary diagnosis, respiratory symptoms, and AAT serum levels were assessed. Whole blood samples were collected as dried blood spots, and the most common AATD mutations were simultaneously tested by allele-specific genotyping.

Results

A total of 1088 patients, mainly diagnosed with COPD (92.7%) and shortness of breath (78.7%), were assessed. Fifty-one (5%) were found to have AATD mutations. Fifteen (29.4%) patients had Pi*S or Pi*Z mutations, whereas 36 (70.6%) patients carried rare alleles Pi*M malton (n=18, 35.3% of mutations), Pi*I (n=8, 16%), Pi*P lowell (n=7, 14%), Pi*M heerlen (n=2, 4%), and Pi*S iiyama (n=1, 2%). The most common heterozygous combinations were Pi*M/Z (n=12, 24%), and Pi*M/M malton (n=11, 22%). Ten patients with severe AATD due to two deficiency alleles were identified, two with the Pi*Z/Z genotype, four with the genotype Pi*M malton/M malton, three with Pi*Z/M malton, and one with Pi*Z/M heerlen.

Conclusion

Our results identified AATD mutations as a genetic-based contributor to lung disease in patients with COPD or bronchiectasis and assessed their frequency in a population of Turkish patients.

Picturing asthma in Turkey: results from the Turkish adult asthma registry

INTRODUCTION

National data on asthma characteristics and the factors associated with uncontrolled asthma seem to be necessary for every country. For this purpose, we developed the Turkish Adult Asthma Registry for patients with asthma aiming to take a snapshot of our patients, thereby assigning the unmet needs and niche areas of intervention.

METHODS

Case entries were performed between March 2018 and March 2022. A web-based application was used to record data. Study outcomes were demographic features, disease characteristics, asthma control levels, and phenotypes.

RESULTS

The registry included 2053 patients from 36 study centers in Turkey. Female subjects dominated the group (n = 1535, 74.8%). The majority of the patients had allergic (n = 1158, 65.3%) and eosinophilic (n = 1174, 57.2%) asthma. Six hundred nineteen (32.2%) of the patients had obese asthma. Severe asthma existed in 670 (32.6%) patients. Majority of cases were on step 3-5 treatment (n: 1525; 88.1%). Uncontrolled asthma was associated with low educational level, severe asthma attacks in the last year, low FEV1, existence of chronic rhinosinusitis and living in particular regions.

CONCLUSION

The picture of this registry showed a dominancy of middle-aged obese women with moderate-to-severe asthma. We also determined particular strategic targets such as low educational level, severe asthma attacks, low FEV1, and chronic rhinosinusitis to decrease uncontrolled asthma in our country. Moreover, some regional strategies may also be needed as uncontrolled asthma is higher in certain regions. We believe that these data will guide authorities to reestablish national asthma programs to improve asthma service delivery.

The Evaluation of Disease Awareness, Caregiver Burden and Workday Loss in Caregivers of COPD Patients

OBJECTIVE

Our aim is to determine the caregiver burden of chronic obstructive lung disease (COPD) patient's caregivers, and to determine whether there is a work day loss.

MATERIAL AND METHOD

252 COPD patients and their caregivers were included. Disease information of the patients were recorded and a questionnaire was applied. Socio-demographic characteristics of the caregivers were recorded and a questionnaire consisting of 24 questions including COPD disease, treatment and loss of working days and Zarit Scale were used.

RESULTS

128(50.8%) of the patients according to GOLD were group-D. 97(38.5%) of the patient's relatives were working. 62(24.7%) were not able to go to work for 1-14 days. 125(57.1%) spent outside the home from 1 to 14 nights, because those accompanied to patients. In univariate analysis were detected modified medical research council (mMRC) (p<0.001), CAT(p<0.001), the number of comorbidities of patients (p=0.027), forced expiratory volume in 1 FEV1cc(p=0.009), FEV1%(p<0.001), the presence of long term oxygen therapy (LTOT) and the number of comorbidities of the patient's relatives (p=0.06) increased the care load. In multipl linear regression analysis, age (p=0.03), COPD assessment test (CAT) score (p=0.001), FEV1%(<0.068) and the number of comorbidities of patients (p=0.01) and the number of comorbidities of caregivers (p=0.003) increased the caregiving burden.

CONCLUSION

In COPD increases caregiving burden. This burden is greater in symptomatic patients and when comorbidities are present. Psycho-social and legal regulations should be investigated and solutions should be produced for the caregivers of COPD patients.

Comparison of inflammation biomarkers among chronic obstructive pulmonary disease groups: A cross sectional study

Background

The Global Initiative classification (GOLD) for chronic obstructive pulmonary disease (COPD), which relies on the practical issues of treatment of this complex and heterogeneous disease, may not be reliable in predicting disease severity and prognosis as the term of inflammation is excluded from the definition.

Aim

The aim of this study was to determine systemic inflammatory markers in GOLD ABCD groups and to compare these parameters according to clinical and functional features.

Methods

The study included 60 COPD patients and 59 healthy subjects. Comparisons were made with the pulmonary function test, transthoracic echocardiography and the six-minute walk test (6MWT). The COPD assessment test (CAT), modified Medical Research Council (mMRC), and index scores of body mass index, airflow obstruction, dyspnea, and exercise capacity (BODE) were recorded. The systemic inflammatory state was assessed using C-reactive protein, fibrinogen, tumor necrosis factor-alpha (TNF-α), interleukin (IL)-6, IL-8 and IL-18.

Results

The levels of all serum inflammatory markers were higher in the COPD group than in the control group. TNF-α and IL-6 were significantly higher in the symptomatic groups (B and D) than in the less symptomatic groups (A and C) (P < 0.05). Spirometric parameters were more severe in Group D, followed by groups C, B and A, respectively. The 6MWT and the BODE scores were worst in Group D, followed by groups B, C and A.

Conclusion

The results suggest that bronchodilator treatment alone might be insufficient in Group B patients, as the systemic inflammatory markers in addition to exercise capacity and mortality predictors were at the worst level in Groups D and B.

Adherence to COPD treatment in Turkey and Saudi Arabia: results of the ADCARE study

Background

COPD affects millions of people worldwide. Poor treatment adherence contributes to increased symptom severity, morbidity and mortality. This study was designed to investigate adherence to COPD treatment in Turkey and Saudi Arabia.

Methods

An observational, cross-sectional study in adult COPD patients in Turkey and Saudi Arabia. Through physician-led interviews, data were collected on sociodemographics and disease history, including the impact of COPD on health status using the COPD Assessment Test (CAT); quality of life, using the EuroQol Five-Dimension questionnaire (EQ-5D); and anxiety and depression using the Hospital Anxiety and Depression Scale (HADS). Treatment adherence was measured using the 8-item Morisky Medication Adherence Scale (MMAS-8). Multivariate logistic regression analysis examined the predictors of non-adherence and the impact of adherence on symptom severity.

Results

Four hundred and five COPD patients participated: 199 in Turkey and 206 in Saudi Arabia. Overall, 49.2% reported low adherence (MMAS-8 <6). Of those, 74.7% reported high disease impact (CAT >15) compared to 58.4% reporting medium/high adherence (p=0.0008). Patients with low adherence reported a lower mean 3-level EQ-5D utility value (0.54±0.35) compared to those with medium/high adherence (0.64±0.30; p<0.0001). Depression with HADS score 8–10 or >10 was associated with lower adherence (OR 2.50 [95% CI: 1.43–4.39] and 2.43 [95% CI: 1.39–4.25], respectively; p=0.0008). Being a high school/college graduate was associated with better adherence compared with no high school (OR 0.57 [95% CI: 0.33–0.98] and 0.38 [95% CI: 0.15–1.00], respectively; p=0.0310). After adjusting for age, gender, and country, a significant association between treatment adherence (MMAS-8 score ≥6) and lower disease impact (CAT ≤15) was observed (OR 0.56 [95% CI: 0.33–0.95]; p=0.0314).

Conclusion

Adherence to COPD treatment is poor in Turkey and Saudi Arabia. Non-adherence to treatment is associated with higher disease impact and reduced quality of life. Depression, age, and level of education were independent determinants of adherence.

Pneumococcal and influenza vaccination status of hospitalized adults with community acquired pneumonia and the effects of vaccination on clinical presentation

BACKGROUND

Previous reports have shown that vaccination rates of adult at-risk populations are low in Turkey. There are differing reports with regards to the effectiveness of the influenza and the pneumococcal polysaccharide vaccine (PPSV23) on the clinical outcomes of community acquired pneumonia (CAP). The purpose of this study was to analyze the influenza (FV) and pneumococcal vaccination (PV) status, the factors that influence the receipt of influenza/pneumococcal vaccine and the effects of prior vaccination on the clinical outcomes in adults hospitalized with CAP.

PATIENTS AND METHODS

Patients hospitalized with CAP between March 2009 and October 2013 and registered at the web-based Turkish Thoracic Society Pneumonia Database (TURCAP) were included in this multicentric, observational study. Of a total of 787 cases, data were analyzed for 466 patients for whom self-reported information on PV and FV was available.

RESULTS

In this adult population with CAP, the vaccination rate with both the pneumococcal and influenza vaccines was found to be 6%. Prior FV was found to be the sole variable that was associated with the receipt of PV [OR 17.8, 95% CI (25-75:8.56-37.01), p < 0.001]. Conversely, being vaccinated with PPSV23 was the only predictor of receipt of FV [OR 18.1, 95% CI (25 - 75:8.75 - 37.83), p < 0.001]. Compared to the unvaccinated cases, the chest radiograms of the vaccinated patients revealed less consolidation. The latter also reported fatigue, muscle pain and gastrointestinal symptoms less frequently. Although there was a trend for lower 30-day mortality and for lower rates of intensive care unit (ICU) admission, these did not reach statistical significance. A pneumonia severity index (PSI) score ≥ 90, CURB-65 score ≥3 and multilobar involvement, but not the vaccination status, were identified as independent determinants of ICU admission.

CONCLUSIONS

This study showed that, among patients hospitalized with CAP, the FV and/or PV rates are low. Prior vaccination does not appear to significantly affect the clinical outcomes.

Modification of the GOLD recommendations for chronic obstructive pulmonary disease to broaden their usage in Turkey

Despite the introduction of numerous national and international COPD guidelines designed to provide clinicians with optimal evidence-based disease management strategies, COPD remains an underdiagnosed and poorly treated disease. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend disease specific diagnosis and management strategies, and they are widely used internationally. In this short report we present the outcomes of a meeting of respiratory experts in Turkey who reviewed the GOLD guidelines and their applicability to the Turkish healthcare system. In particular, we were interested to investigate the possibility of developing a simplified version of the combined assessment model which we believe will be more acceptable to Turkish pulmonologists and will increase its use in everyday clinical practice.

Hypertrophic pulmonary osteoarthropathy on bone scintigraphy and 18F-fluorodeoxyglucose positron emission tomography/computed tomography in a patient with lung adenocarcinoma

Hypertrophic pulmonary osteoarthropathy (HPOA) is not an uncommon paraneoplastic syndrome that is frequently associated with lung cancer. A 54-year-old male patient with lung adenocarcinoma underwent bone scintigraphy and fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scanning for initial staging. Bone scintigraphy revealed increased periosteal activity in lower extremities. FDG PET/CT revealed hypermetabolic right lung mass, mediastinal lymph nodes, and mildly increased periosteal FDG uptake in both femurs and tibias. The findings in lower extremities on bone scan and FDG PET/CT were interpreted as HPOA.

[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.

Anthropometric methods in evaluation of chronic obstructive pulmonary disease

Chronic Obstructive Pulmonary Disease (COPD) is mainly expressed by weight loss with especially fat-free mass (FFM) depletion and a low body weight correlates with increased mortality and a poor prognosis. We investigated whether anthropometric body composition equations could be used for evaluation of the body composition in COPD. Thirty clinically stable patients with COPD and 13 healthy age matched control subjects underwent the skinfolds and circumference measurements in addition to body mass index (BMI) calculations. Body fat mass (BFM) and FFM were determined by using anthropometric equations. The percent BFM, predicted from body density either using Siri's or Brozek's equations was determined lower than that of calculated with equations by using BMI, age and gender. The values of BFM and body weight were reduced in patients with FEV1 < % predicted compared to other participants. The FFM values also dropped depending on the severity of COPD. BMI was not statistically different among the participants while FFM index (FFMI) reflected the nutritional status of the disorders. Anthropometric equations easily and cost effectively applied for prediction of % BFM, FFM, and FFMI in patients with COPD. In addition, the FFMI can be possibly used for expressing COPD severity.

Smoking habits in the Middle East and North Africa: results of the BREATHE study

Few recent comparative data exist on smoking habits in the Middle East and North Africa (MENA) region. The objective of this analysis was to evaluate smoking patterns in a large general population sample of individuals aged ≥ 40 years in ten countries in the region (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), together with Pakistan, using a standardised methodology. A random sample of 457,258 telephone numbers was generated and called. This identified 65,154 eligible subjects, of whom 62,086 agreed to participate. A screening questionnaire was administered to each participant, which included six questions relating to cigarette consumption and waterpipe use. The age- and gender-adjusted proportion of respondents reporting current or past smoking of cigarettes or waterpipes was 31.2% [95% CI: 30.9-31.6%]. This proportion was significantly higher (p < 0.001) in men (48.0%) than in women (13.8%), but no relevant differences were observed between age groups. Smoking rates were in general lowest in the Maghreb countries and Pakistan and highest in the Eastern Mediterranean countries, ranging from 15.3% in Morocco to 53.9% in Lebanon. Consumption rates were 28.8% [28.4-29.2%] for cigarette smoking and 3.5% [3.4-3.6%] for waterpipe use. Use of waterpipes was most frequent in Saudi Arabia (8.5% of respondents) but remained low in the Maghreb countries (< 1.5%). Cumulative cigarette exposure was high, with a mean number of pack · years smoked of 18.5 ± 20.5 for women and 29.1 ± 26.2 for men. In conclusion, smoking is a major health issue in the MENA region.

Microalbuminuria, von Willebrand factor and fibrinogen levels as markers of the severity in COPD exacerbation

In COPD, the systemic effects of the disease reflect the structural and/or biochemical alterations occurring in the structures or organs other than the lungs in relation to the characteristics of the primary disease. The disorders of endothelial structures due to COPD may lead vascular pathologies, such as ischemic heart disease, stroke, to occur more commonly in those with COPD. On consideration of the fact that the vascular endothelium is a major site in which the systemic effect of the inflammation occurs, should von Willebrand Factor, a clotting factor of endothelium origin, and the plasma level of fibrinogen vary with the severity of the disease in COPD, the variability of arterial blood gas values, and the stability or exacerbation of the disease? Considering the fact that microalbuminuria is an indirect manifestation of the renal endothelial permeability and/or renal perfusion; should there be an association between microalbuminuria and the severity of COPD? Therefore, in order to assess the effect of the systemic inflammation in COPD on the vascular endothelium, we compared the levels of the plasma vWF, fibrinogen, 24-h urine microalbuminuria of those with stable COPD (33 patients) and exacerbation of COPD (26 patients) with those of the controls (16 healthy subjects). The mean age was 63.42 -/+ 10.29, 68.00 -/+ 9.77 and 59.63 -/+ 14.10 years in SCOPD, COPDAE, and CG, respectively. The level of microalbuminuria was found to increase significantly in COPDAE group, compared to that of the controls (P = 0.004). When we investigated the relation between smoking burden and microalbuminuria, vWF, fibrinogen levels, the amount of consumption and positive relationship were found significant. (r = 0.336, P = 0.003 between smoking pack-years and vWF, r = 0.403, P = 0.001 between smoking pack-years and fibrinogen, and r = 0.262, P = 0.02 between smoking pack-years and microalbuminuria). The levels of vWF and fibrinogen are AECOPD > SCOPD > CG, with the highest being in AECOPD, and the difference among the groups was statistically significant. The relationship between the level of hypoxemia and microalbuminuria, fibrinogen and vWF was found to be significant (r = -0.360, P = 0.005 between oxygen saturation and microalbuminuria, r = -0.359, P = 0.005 between the level of PaO(2) and fibrinogen, and r = -0.336, P = 0.009 between PaO(2) and vWF). In conclusion, the levels of plasma vWF, fibrinogen, and microalbuminuria may be helpful in grading the severity of COPD exacerbation. The related increase in these markers may represent a possible pathophysiological mechanism behind the increased vascular morbidity of patients with COPD and detecting indirectly the endothelial dysfunction as a manifestation of systemic outcomes due to COPD and in detecting earlier the cases in which the risk for developing the associated complications are higher. We suggest that further studies are necessary to investigate the impact of antithrombotic treatment on microalbuminuria, plasma vWF and fibrinogen as markers of endothelial dysfunction coexisting COPD exacerbation.

[The effect of spinal anesthesia on pulmonary function tests in old patients]

Pulmonary function test (PFT) results are mainly dependent on age, sex, height, weight, pulmonary mechanics disturbances and cooperation of the subjects. The position and anesthesia type may also influence the PFT results. In this study we aimed to evaluate spirometric changes in old and young patients who performed spinal anesthesia. Fifty patients performed spinal anesthesia were randomized in two groups: Group 1 (n= 25) aged 60-85 years old and group 2 (n= 25) aged 20-59 years old. After electrocardiography, noninvasive blood pressure and peripheral oxygen saturation (SpO2) monitorization, spinal anesthesia using 0.5% hyperbaric bupivacain from L 3-4 intervertebral space was applied. Sensory block levels, hemodynamics and PFT such as forced vital capacity (FVC), forced expiratory volume/1 second (FEV(1)), peak expiratory flow (PEF), and forced expiratory flow at the 25 and 75% of the pulmonary volume (FEF(25-75)) were performed before and after spinal anesthesia in 10th, 40th and 100th minutes in supine and 30 degrees head position using hand type spirometry. Wilcoxon paired two tests statistical analysis was used to compare PFT changes of the subjects. Mean arterial blood pressure levels and spirometric measurements of FVC, FEV(1) and FEF25-75 decrease with respect to basal values in 40th minutes was significant in old patients whom spinal anesthesia was over Th6 level but in young patients the changes were not significant. PFT decrement probabilities should be taken in account in old patients supposing for spinal anesthesia and be paid attention for high level spinal blocks in risk group patients.

Role of arterial blood gas abnormalities in oedema formation in COPD

OBJECTIVE

Renal and hormonal abnormalities, manifesting as oedema or hyponatraemia, are often seen in patients with COPD. The aim of this study was to investigate the effect of airflow obstruction and arterial blood gas abnormalities on oedema formation in COPD patients.

METHODOLOGY

A total of 58 COPD patients hospitalized for treatment of COPD exacerbation were admitted to the study. Of these, 38 patients had peripheral oedema (group 1) and 20 patients had no oedema (group 2).

RESULTS

The mean age was 68 +/- 9 years in group 1 and 68 +/- 8 years in group 2. On the first day of admission, serum urea was 29.18 +/- 12.25 mg/dL and creatinine was 1.62 +/- 0.46 mg/dL in group 1, while urea was 15.50 +/- 4.59 mg/dL and creatinine was 1.07 +/- 0.10 mg/dL in group 2. Hyponatraemia occurred in five patients (13%) in group 1 and one patient (5%) in group 2. There was no difference in severity of airflow obstruction in the two groups; FEV1 was 44 +/- 15% of predicted and FEV1/FVC was 53 +/- 14 in group 1, while FEV1 was 45 +/- 16% of predicted and FEV1/FVC was 54 +/- 20 in group 2. There were statistically significant differences in pH (7.32 vs. 7.39; P= 0.013) and in PaCO2 (62 +/- 10 mmHg vs. 42 +/- 6; P= 0.048) for group 1 compared with group 2. PaO2 (62 +/- 17 mmHg vs. 82 +/- 27) and SaO2 (87 +/- 9%vs. 90 +/- 13) were found to be lower in group 1 compared with group 2 but the difference did not reach statistical significance.

CONCLUSION

Alterations in pH and PaCO2 (respiratory acidosis and hypercapnia) appear to have more prominent roles than hypoxaemia in oedema formation in COPD patients.

[Bronchiolitis obliterans organizing pneumonia presenting with solitary pulmonary nodule and spontan pneumothorax]

Chronic obstructive pulmonary disease (COPD) is characterized with progressive airflow limitation as a result of abnormal inflammation due to inhalation of various noxious gases and particulate dusts. COPD is an increasing important health problem that is parallel to the increasing habit of tobacco smoke. Tracheobronchial infections seem to be the most important cause of exacerbation in COPD, however pneumothorax and pulmonary thromboembolism are also important determinant factors in the attack's severity. Since the tobacco smoking is the common risk factor in both COPD and lung cancer, solitary pulmonary nodules especially in smokers should be carefully examined. Bronchiolitis obliterans organizing pneumonia (BOOP) is an uncommon pulmonary disorder, the clinical spectrum of which is variable. In this case report, a COPD patient manifesting spontaneous pneumothorax and solitary pulmonary nodule has been discussed who was diagnosed as BOOP after surgical procedure.

Cavitary Necrobiotic Nodule Imitating Malignant Lung Disease in a Patient Without Articular Manifestations of Rheumatoid Arthritis

Pulmonary involvement is a serious complication of rheumatoid arthritis (RA) and may be seen as airway disease, rheumatoid nodules, interstitial lung disease, and pleurisy. However, cavitary rheumatoid nodules without articular manifestations are rare. We describe a male patient presenting with pleurisy and multiple rheumatoid necrobiotic nodules in the absence of arthritis or subcutaneous nodules. One of the nodules was quite large (5 x 8 cm in diameter) and cavitary, imitating bronchial carcinoma radiologically and bronchoscopically. Definite histopathologic diagnosis was obtained by open lung biopsy. The patient was given methylprednisolone and methotrexate, and significant regression was observed in clinical and radiologic findings. He has been followed for 14 months with no articular manifestations yet, receiving 4 mg/d methylprednisolone and 20 mg/wk methotrexate. The diagnosis of rheumatoid pulmonary involvement without articular manifestations can be difficult. Rheumatoid nodules may imitate bronchial carcinoma, or bronchial carcinoma may coexist in RA patients. Open lung biopsy may be necessary for differential diagnosis of pulmonary lesions in RA.

Respiratory impairment due to asbestos exposure in brake-lining workers

There is extensive evidence that exposure to asbestos causes pulmonary parenchymal fibrosis, pleural disease, and malignant neoplasm in asbestos-exposed workers. However, few data concerning brake-lining workers are available in the literature. In this study, we aimed to assess the long-term effects of chrysotile asbestos exposure on lung function and the risk of asbestos-related diseases in brake-lining workers. Seventy-four asbestos-exposed workers who processed brake-lining products and 12 unexposed office workers were offered pulmonary function tests (spirometry and transfer factor) in 1992 and 1999. In 1999, the mean duration of asbestos exposure was 10.00+/-4.07 and 11.02+/-4.81 years (7-31 years) in nonsmoking and smoking asbestos workers, respectively. Transfer factor (T(L), CO) and transfer coefficient (K(CO)) decline were significant in the 7-year follow-up in both smoking and nonsmoking asbestos workers. However, lung function indices of the control group, whom were all current smokers; were also found to be decreased, including FEF(75), T(L), CO and K(CO). We found minimal reticular changes in 10 asbestos workers who were all current smokers, they underwent high-resolution computed tomography scans of the chest and we found that they had peribronchial thickening resulting from smoking. As a conclusion, even in the absence of radiographic asbestosis, T(L), CO and K(CO) may decrease after a mean 10-year duration of exposure to asbestos in brake-lining workers and this is more noticeable with cigarette burden.

Migratory nodules in the lung: lymphomatoid granulomatosis

A 45-year-old woman was admitted with complaints of non-productive cough, chest pain, fatigue and weight loss in the last 4 months. On physical examination moderate hepatosplenomegaly and crackles most notably on the basal region of the right lung were evident. Serial chest X-rays and computed tomographies revealed a migratory nodular infiltration pattern, changing in location and size in both the lungs. The histopathological diagnosis of the open lung biopsy was lymphomatoid granulomatosis (LG) with a marked angioinvasive lymphocytic perivascular and peribronchial infiltration pattern. In the immunohistochemical analyses LCA, CD-79, CD-20 were positive, while CD-30 was negative. No response could have been achieved under combination chemotherapy and the patient died from progressive disease. LG is a rare disease and a difficult diagnosis in the routine clinical practice. This report emphasises that, LG should be considered especially when there are migratory nodules of varying sizes in lungs.

Transthoracic echocardiographic documentation of disappearance of massive pulmonary artery thromboemboli after fibrinolytic therapy

In this paper, we report two cases of acute massive pulmonary thromboemboli with pulmonary artery thrombus, in which disappearance of thrombus followed fibrinolytic therapy were documented at transthoracic echocardiographic follow-up. Data from these limited experiences suggest that, transthoracic echocardiography might be useful as a first diagnostic screening in cases of suspect pulmonary thromboembolism and thrombolytic therapy might be considered in patients with pulmonary artery thrombus with pulmonary embolism.

Perlite exposure and 4-year change in lung function

Perlite is a volcanic glass or amorphous aluminium silicate composed of 71-75% SiO(2). When heated to 800-1100 degrees C, it expands to form processed perlite, which has a low density, high surface area, and a low thermal conductivity. The objective was to determine the effect of perlite exposure on pulmonary function tests. Pulmonary function tests in conjunction with chest radiogram were carried out in 36 perlite-exposed workers and 22 unexposed office workers in 1992 and 1996. Respirable dust level exceeded permissible dust levels in work places in the 4 years under study. Transfer coefficient (K(CO)) decline was significant in nonsmoker perlite-exposed workers (n=9), and found to be 5.28+/-0.71 (predicted 4.32+/-0.11) and 3.84+/-0.96 (predicted 4.18+/-0.18) 1/min/mmHg, in 1992 and 1996, respectively (P<0.001). Both smoker perlite workers and office workers showed significant obstruction to airflow in small airways with respect to predicted values and 4-year change in transfer factor (T(L), CO) was significant. Although predicted, 12-year perlite exposure did not lead to a decrease in mean pulmonary function test parameters, there was a tendency to a decline in T(L), CO in the 4-year study period, which may be due to high perlite dust levels. As early effects of perlite dust exposure may not be detected by spirometric measurements alone, the transfer coefficient should be added to spirometry.

Pulmonary function tests in Parkinson's disease

Morbidity and mortality are usually caused by respiratory disorders in Parkinson's disease (PD) because of pulmonary functional impairments. The purpose of this study was to determine the effects of PD on ventilatory function and that the use of pulmonary function tests (PFT) may serve as an indicator of PD severity. PFT have been performed in 21 patients with PD (15 non-smoker and six exsmoker with 36.17 +/- 26.54 pack-years of smoking history; mean age 64.67 +/- 10.76 years) and 16 normal age-matched control subjects who never smoked. The clinical disability was indicated by a Hoehn-Yahr (H-Y) scale. MEF25% [maximal flow rate at 25% of remaining forced vital capacity (FVC)] and FEV1 (the volume of air expired during the first second of the FVC) in exsmoker PD group was lower than non-smoker PD group (P < 0.05). The two effort dependent variables' peak expiratory flow (PEF) and the maximal flow rate at 75% of the remaining FVC (MEF75%) percent predicted values were 70.66 +/- 24.15 and 69.05 +/- 24.39 in non-smoker PD group whereas 90.18 +/- 17.24 and 90.00 +/- 18.97% predicted were in control group, respectively (P < 0.05). The maximal voluntary ventilation (MVV) was found to be 52.83 +/- 15.52 and 91.52 +/- 13.80% in PD and control group, respectively (P < 0.0001). MVV was the most effected parameter that was inversely correlated with the PD severity (r=-0.87, P < 0.0001). We concluded that less coordinated and less explosive muscle force has contributed to decrease in PEF and MEF75% values, and MVV decreases in PD as a result of the impaired performance and reduced efficiency during repetitive motor tasks which in part reflects abnormal agonist-antagonist muscle activity. So, spirometric studies may serve as a useful indicator of patients' neurophysiological conditions for the purpose of anticipating and preventing complications because of pulmonary impairment.