Risk Medicine and Transhumanism

New developments in bioinformatics, artificial intelligence, and nano-biotechnologies will radically change the practice of medicine to be exhibited in the coming years. One approach that has the potential to carry this changing medical practice into a superhuman age and that has been dominating medical literature in recent years is the risk approach. This article aims to address the issue beyond the dichotomy of good or evil without wrapping the practice of medicine exhibited throughout the human body and history in the sacrament of holiness and falling into the traps of bioconservatism and solutionism.

The association of antiviral drugs with COVID-19 morbidity: The retrospective analysis of a nationwide COVID-19 cohort

Background and objectives

Although several repurposed antiviral drugs have been used for the treatment of COVID-19, only a few such as remdesivir and molnupiravir have shown promising effects. The objectives of our study were to investigate the association of repurposed antiviral drugs with COVID-19 morbidity.

Methods

Patients admitted to 26 different hospitals located in 16 different provinces between March 11–July 18, 2020, were enrolled. Case definition was based on WHO criteria. Patients were managed according to the guidelines by Scientific Board of Ministry of Health of Turkey. Primary outcomes were length of hospitalization, intensive care unit (ICU) requirement, and intubation.

Results

We retrospectively evaluated 1,472 COVID-19 adult patients; 57.1% were men (mean age = 51.9 ± 17.7years). A total of 210 (14.3%) had severe pneumonia, 115 (7.8%) were admitted to ICUs, and 69 (4.7%) were intubated during hospitalization. The median (interquartile range) of duration of hospitalization, including ICU admission, was 7 (5–12) days. Favipiravir (n = 328), lopinavir/ritonavir (n = 55), and oseltamivir (n = 761) were administered as antiviral agents, and hydroxychloroquine (HCQ, n = 1,382) and azithromycin (n = 738) were used for their immunomodulatory activity. Lopinavir/ritonavir (β [95% CI]: 4.71 [2.31–7.11]; p = 0.001), favipiravir (β [95% CI]: 3.55 [2.56–4.55]; p = 0.001) and HCQ (β [95% CI]: 0.84 [0.02–1.67]; p = 0.046) were associated with increased risk of lengthy hospital stays. Furthermore, favipiravir was associated with increased risks of ICU admission (OR [95% CI]: 3.02 [1.70–5.35]; p = 0.001) and invasive mechanical ventilation requirement (OR [95% CI]: 2.94 [1.28–6.75]; p = 0.011).

Conclusion

Our findings demonstrated that antiviral drugs including lopinavir, ritonavir, and favipiravir were associated with negative clinical outcomes such as increased risks for lengthy hospital stay, ICU admission, and invasive mechanical ventilation requirement. Therefore, repurposing such agents without proven clinical evidence might not be the best approach for COVID-19 treatment.

Clinical Predictors of Response to Tocilizumab: A Retrospective Multicenter Study

OBJECTIVE:

MATERIAL AND METHODS:

Results:

Conclusion:

COVID-19 Outbreak in İstanbul

OBJECTIVE

Material and Methods

Results

Conclusion

The predictors of COVID-19 mortality in a nationwide cohort of Turkish patients

The COVID-19-related death rate varies between countries and is affected by various risk factors. This multicenter registry study was designed to evaluate the mortality rate and the related risk factors in Turkey. We retrospectively evaluated 1500 adults with COVID-19 from 26 centers who were hospitalized between March 11 and July 31, 2020. In the study group, 1041 and 459 cases were diagnosed as definite and highly probable cases, respectively. There were 993 PCR-positive cases (66.2%). Among all cases, 1144 (76.3%) were diagnosed with non-severe pneumonia, whereas 212 (14.1%) had severe pneumonia. Death occurred in 67 patients, corresponding to a mortality rate of 4.5% (95% CI:3.5–5.6). The univariate analysis demonstrated that various factors, including male sex, age ≥65 years and the presence of dyspnea or confusion, malignity, chronic obstructive lung disease, interstitial lung disease, immunosuppressive conditions, severe pneumonia, multiorgan dysfunction, and sepsis, were positively associated with mortality. Favipiravir, hydroxychloroquine and azithromycin were not associated with survival. Following multivariate analysis, male sex, severe pneumonia, multiorgan dysfunction, malignancy, sepsis and interstitial lung diseases were found to be independent risk factors for mortality. Among the biomarkers, procalcitonin levels on the 3rd-5th days of admission showed the strongest associations with mortality (OR: 6.18; 1.6–23.93). This study demonstrated that the mortality rate in hospitalized patients in the early phase of the COVID-19 pandemic was a serious threat and that those patients with male sex, severe pneumonia, multiorgan dysfunction, malignancy, sepsis and interstitial lung diseases were at increased risk of mortality; therefore, such patients should be closely monitored.

COVID-19 Pandemic Threatening Prison Population

The prison population is one of the high-risk groups for coronavirus disease 2019 (COVID-19) pandemic. Apart from being in disadvantageous settings of "social distancing," people in prisons are frequently elderly and with multiple comorbidities as a reflection of discriminatory punitive policies worldwide. Although the universal human rights principles ensure that prisoners, like everyone else, live their lives in a healthy environment and access qualified healthcare when they are sick, without being discriminated, the prison conditions make it difficult to comply with these principles. In this review, the basic principles and recommendations on this subject have been reviewed in the context of the COVID-19 outbreak. In addition, the situation in Turkey's prisons was reviewed immediately before the transition to a "controlled social life."

COVID-19 Pandemic and the Global Perspective of Turkish Thoracic Society

It has been more than 3 months now since the first case of COVID-19 was reported in Turkey. Globally, the number of confirmed cases and deaths reached 9,653,048 and 491,128 respectively, as reported by 216 countries by June 27, 2020. Turkey had 1,396 new cases, 194,511 total cases, and 5,065 deaths by the same date. From the first case until today, the Turkish Thoracic Society (TTS) has been very proactive in educating doctors, increasing public awareness, undertaking academic studies, and assisting with public health policies. In the present report, social, academic, and management perspectives of the pandemic are presented under appropriate subtitles. During this critical public health crisis, TTS has once again demonstrated its readiness and constructive stance by supporting public health, healthcare workers, and the environment. This review summarizes the perspective of TTS on each aspect of the COVID-19 pandemic and casts light on its contributions.

Association between pulmonologists' tobacco use and their effort in promoting smoking cessation in Turkey: a cross-sectional study

Background

A strategy to reduce the number of smoking-related deaths is to encourage the involvement of health-care professionals in tobacco-use prevention activities and cessation counseling. Previous studies have shown that physicians’ smoking status affects their efforts to provide smoking cessation counseling. This study investigates the association between pulmonologists’ tobacco use and their efforts in promoting smoking cessation during their routine clinical practices in Turkey.

Methods

This cross-sectional study was performed among active members of the Turkish Thoracic Society (TTS) between June 2010 and February 2011 using an Internet-based self-administered questionnaire. Participants gave their written informed consent. The survey included questions about responders’ sociodemographics, smoking status, and their routine clinical practice for smoking cessation counseling using the basic 5A’s (Ask, Advise, Assess, Assist, and Arrange) of smoking cessation counseling. According to the total score for the 5A’s protocol, smoking cessation counseling was dichotomized into low- and high-effort groups in promoting smoking cessation. Pearson’s chi-square test and t-test were used to compare groups and logistic regression models for the research question, which was approved by the TTS Scientific Ethical Committee.

Results

The response rate was 41 % (N = 699/1701); 9.9 % were current smokers, and 72.7 % indicated that they provided high effort in promoting smoking cessation. A univariate analysis showed that noncurrent smokers were more likely to make a high effort than current smokers (odds ratio [OR], 1.82; 95 % confidence interval [CI]: 1.09–3.05; P = 0.02). However, there was no association between tobacco use (current smoking) and making high effort in promoting smoking cessation after controlling for the two confounders, sex and practicing in smoking cessation outpatient clinic (OR, 1.47; 95 % CI: 0.86–2.50; P = 0.1).

Conclusions

Despite low response rate in our study and suspicions of underreporting, the smoking rate among the pulmonologists in our study was high. Non-current smokers were more likely to provide high effort in promoting smoking cessation compared to current smokers in univariate analysis. However, after controlling for the two confounders, sex and practising in SCOC, there was no association between tobacco use and providing high effort in promoting smoking cessation. Thus, improving medical school education, specialty training and post-graduate training on smoking cessation counseling may positively affect physician' effort in promoting smoking cessation.

Ethical Issues in Tuberculosis Control

Tuberculosis (TB) remains a major global public health problem as also defined by the World Health Organization (WHO). On the other hand, the incidence of TB worldwide decreases at a lower rate than the intended targets, and it is seen that the targets set for 2015 will not be achieved at the global level. According to the WHO, failure to achieve the targets in TB control results from "resource constraints", "conflict and instability" and "generalized human immunodeficiency virus epidemics". This article is aimed to maintain an ethical debate in TB control and to investigate the WHO's TB control policy and question the reasons for failure of this policy. Within the scope of this article; the TB of TB control was problematized at macro political level within the context of philosophy, while the approach of health care staff to TB patients was analysed at micro level within the context of professional ethics.

[The frequency of performing smoking cessation outpatient clinic in chest disease specialists who are members of Turkish Thoracic Society and factors affecting this performance]

INTRODUCTION

Although helping patients to stop smoking is a good clinical practice that has to be carried out by physicians everywhere and in every area, it is known that carrying out this help systematically in accordance to a programme in smoking cessation outpatient clinics significantly improves the chance of success.

MATERIALS AND METHODS

The study is a cross-sectional survey performed among chest disease specialists who are members of Turkish Thoracic Society (TTS), between June 2010 and February 2011. As independent variables relevant to status of performing/not performing Smoking Cessation Outpatient Clinic (SCOC); sex, age (younger or older than 40), being graduated before or after 1996, being or not being in a consultant position, work place (Hospital of Ministry of Health/private hospital/university hospital), having or not having an education for smoking cessation help and being or not being member of a City Tobacco Control Committee (CTCC) were investigated. Data was collected via a web-questionnaire prepared by using WHO Global Health Professionals Questionnaire which was sent to members through TTS secreteriat.

RESULTS

41% (699/1701) of members of TTS responded. 39.5% of responders reported that they perform SCOC. When the factors possibly affecting the performance of SCOC are evaluated with logistic regression analysis; being graduated after 1996, having an education for smoking cessation help, being a member of CTCC and not being an active smoker are found to improve this performance.

CONCLUSION

Our study showed that having an education for smoking cessation help (and tobacco control) makes chest disease specialists get more responsibility on this topic. Accordingly, continuous efforts for improving awareness of personal and social responsibilities of all physicians, especially chest disease specialists, have to be made to provide their taking active roles in tobacco control.

Obstructive sleep apnea is prevalent in patients with pulmonary embolism

Purpose: Obstructive sleep apnea (OSA) syndrome causes systemic consequences due to hypoxia and endothelial dysfunction. The purpose of this study was to investigate whether OSA is more common in subjects with pulmonary embolism (PE). Methods: This prospective study was conducted between November 2009 and December 2010 in the Department of Pulmonary Medicine of Gaziantep University. Twenty-eight patients with PE were included in the study group along with forty-five subjects with OSA as the control group. The control group was selected from among subjects who were referred to the sleep clinic. Full night polysomnography was performed for each subject. Results: Mean apnea-hypopnea index (AHI) was found to be higher in the PE group compared with the control group (p=0.010). Severe OSA was detected in 21.4% of the PE group but in no controls (p=0.015). Sleep stage 2 was longer in control group whereas stage 1 and rapid eye movement (REM) sleep was longer in the PE group. Snoring and excessive daytime sleepiness were more common in the control group compared with the study group. AHI severity and thrombus localization were not significantly different between the groups (p=0.350). Conclusion: Our study findings suggest that OSA is more prevalent and severe in subjects with PE compared with control subjects. The clinical significance of less prevalent excessive daytime sleepiness and snoring in subjects with PE should be evaluated in further studies.

Factors influencing compliance with continuous positive airway pressure ventilation in obstructive sleep apnea syndrome

INTRODUCTION

Positive pressure ventilation is considered first line therapy in obstructive sleep apnea syndrome however compliance is limited by various factors. We aimed to investigate possible factors influencing compliance.

MATERIALS AND METHODS

One hundred and forty patients were prescribed positive pressure ventilation for obstructive sleep apnea during June 2006-June 2008. Of these patients, 77% (n= 108) were reached by telephone and a questionnaire was administered regarding factors influencing treatment compliance. Airway passage was measured with C2 vertebrae level and narrowest airway passage on lateral skull radiographs.

RESULTS

The mean age was 52.2 ± 12.3 years. Seventy one percent (n= 77) of subjects obtained the prescribed device. There was no difference in sex, age, marital status, educational level, symptoms, co-morbid conditions, and social security coverage between the subjects who have received the prescribed devices and who have not (p> 0.05). No difference was detected between these two groups of patients in view of Epworth sleepiness scale (ESS) and apnea hypopnea index (AHI). Mean duration of device usage was 6.3 ± 2.3 hours. The device use compliance was not affected by any of the following factors: age, gender, level of education, co-morbid diseases, ESS score, AHI, airway passage measurements, application of humidification and education concerning the device (p> 0.05). Patient (p= 0.057) and bed partners (p= 0.001) satisfaction about the device yielded higher compliance rates.

CONCLUSION

Factors influencing compliance rates in obstructive sleep apnea syndrome seems to be related to satisfaction about the device use however upper airway morphology measured with C2 vertebrae level and narrowest airway passage has no impact on treatment compliance.

Churg-Strauss syndrome related to montelukast

A young male with complaints of cough, dyspnea and hemoptysis was admitted. He was using fluticasone propionate and salmeterol for two years for his asthma. Leukotriene receptor antagonist was prescribed two weeks prior to his admission and no reduction of his inhaled steroid therapy was performed. Eosinophil count was detected as 1460/mm³ (15%) and immunoglobulin E level was 547 IU/mL. Thorax computerized tomography revealed patchy infiltration. Increased eosinophilic inflammation were detected in bronchoalveolar lavage fluid and transbronchial biopsy. He received prednisolone treatment for Churg-Strauss syndrome. Improvement was observed on three months follow up period. He has no complaint in his follow up.

Combined transbronchial needle aspiration and PET/CT for mediastinal staging of lung cancer

In this study, we aimed to evaluate the performance of transbronchial needle aspiration (TBNA) combined with positron emission tomography/computed tomography (PET/CT) for the staging of lung cancer. Twenty-five patients having lymphadenopathies greater than 1 cm on thorax CT and maximum standardized uptake value (SUVmax) ≥ 2.5 on PET/CT were included in this prospective study performed between March 2006 and March 2008. Forty-three lymphnode stations were sampled by using TBNA. Surgical histology, as confirmed by mediastinoscopy, was accepted as the "gold standard". The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of combined TBNA and PET/CT for correct lymph node staging were 67%, 100%, 100%, 76% and 84%; respectively. The initial clinical staging was downstaged after TBNA in 13/19 (69%) patients with adequate TBNA samples, whereas staging was correct in 17/19 (89%) patients assessed by combined TBNA and PET/CT. Staging was completed by TBNA, without mediastinoscopy, in 6/25 (24%) patients. Among the clinical factors that were assessed, only the PET SUVmax was associated with positive TBNA results [odds ratio (OR) 1.27, 95% CI 1.004-1.61, p= 0.046]. A PET SUVmax ≥ 5 was eleven times more likely in patients with positive TBNA results [OR 10.68, 95% CI 1.91-59.62, p< 0.01]. In conclusion, the combination of TBNA with PET/CT increased the sensitivity of TBNA. Combined TBNA and PET/CT may also allow adequate mediastinal staging of lung cancer in most patients with enlarged lymph nodes, and reduce the need for mediastinoscopy. The SUVmax cut off point for a positive TBNA result was ≥ 5.

Impact of CPAP treatment on cardiac biomarkers and pro-BNP in obstructive sleep apnea syndrome

OBJECTIVE

To evaluate the effect of continuous positive airway pressure (CPAP) therapy on pro-brain natriuretic peptide (BNP) and cardiac markers in patients with obstructive sleep apnea syndrome and normal cardiac function.

METHODS

Thirty-three consecutive patients with sleep apnea syndrome were analysed for serum pro-BNP and cardiac markers prior to and after 6 months of CPAP therapy.

RESULTS

Twenty five patients had normal (83.3%) while remaining five (16.7%) revealed high pro-BNP values. We did not detect any significant difference between severity of obstructive sleep apnea syndrome and serum pro-BNP levels (p = 0.534). A statistically significant difference was not observed between basal and sixth-month creatine kinase (CK), creatine kinase-MB (CK-MB), troponin I, pro-BNP, aspartate transaminase (AST), and CK levels in patients with sleep apnea syndrome (p > 0.05).

CONCLUSION

Obstructive sleep apnea syndrome does not induce myocardial damage enough to increase serum pro-BNP, CK, CK-MB, troponin I, and AST levels. Markers sensitive to ischemia could be preferred to evaluate effect of obstructive sleep apnea syndrome.

Diffuse alveolar haemorrhage due to 5-nitroimidazole treatment

Diffuse alveolar haemorrhage (DAH) is indicated by the presence of red blood cells, fibrin and haemosiderin deposits in the lung parenchyma. We present a case of DAH in a 25-year-old male following 5-nitroimidazole treatment. The first episode of haemoptysis occurred following metronidazole treatment 10 months previously. The second episode of haemoptysis occurred following ornidazole treatment 10 days before admission. During his first admission, the patients haemoglobin concentration decreased to 40 g/L. The CXR was normal, whereas high resolution CT of the lungs revealed a diffuse acinonodular pattern. Serological tests for connective tissue diseases were negative. The haemorrhagic appearance of the BAL fluid obtained during fibreoptic bronchoscopy was consistent with DAH. Microbiological analysis of the BAL fluid showed no evidence for bacterial or mycobacterial infection. Haemosiderin laden macrophages were detected in BAL fluid and lung biopsy specimens. DAH due to use of 5-nitroimidazole was diagnosed on the basis of the patient's previous history and complete recovery following treatment with corticosteroid. This is the first reported case of DAH due to use of 5-nitroimidazole. Physicians should be aware of this side-effect when prescribing this group of drugs to patients.

High adenosine deaminase activity in the pleural effusion of a patient with Legionnaires' disease

Although Legionnaires' disease (LD) is frequently accompanied by pleural effusion, the characteristics of pleural effusions in LD have not been well studied. Levels of adenosine deaminase (ADA) activity in pleural fluid >40 IU/L have a high sensitivity (81-100%) and specificity (83-100%) for tuberculosis. ADA activity in pleural effusions due to LD has not been previously reported. The case of a patient with LD complicated by a pleural effusion with high ADA activity is reported. In countries where the prevalence of tuberculosis is high and pleural fluid ADA activities are frequently measured, LD should be included in the differential diagnosis of an exudative pleural effusion with high ADA activity.

Transbronchial needle aspiration in the diagnosis and staging of lung cancer

OBJECTIVES

This study was aimed to determine effects of transbronchial needle aspiration (TBNA) in diagnosis and staging of lung cancer.

METHODS

Records of 55 patients who underwent TBNA in our Chest Department from February 2002 to December 2004 were reviewed retrospectively.

RESULTS

Out of 55 patients who had undergone TBNA, 30 were diagnosed to have lung cancer after complete work up. Transbronchial needle aspiration was positive for malignant cells in 12 out of 20 lung cancer patients with mediastinal lymphadenopathy on computed tomographic scan (CT scan) of the thorax. Mediastinoscopy was positive for malignancy in three cases and the remaining five had bulky lymph node enlargement which was considered malignant, given the histologic diagnosis established by other methods. Transbronchial needle aspiration was also positive for two other patients who had lymph nodes less than 1 cm size. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of TBNA in the diagnosis of lung cancer patients were 58%, 100%, 100%, 37% and 66%, respectively.

CONCLUSIONS

The study demonstrates that TBNA is an efficient procedure in the diagnosis and staging of lung cancer. The diagnostic yield is increased when there is lymph node enlargement on CT scan of the thorax and reduces the need for mediastinoscopy.

Catamenial hemoptysis

Catamenial hemoptysis is a rare condition that is associated with the presence of intrapulmonary or endobronchial endometrial tissue. We describe a case of endobronchial endometriosis with catamenial hemoptysis. The patient was a 22 years-old girl presented with recurrent hemoptysis episodes for the last two years. Bronchoscopic examination was performed within first days of menses, and indicated multiple purplish-red submucosal patches in distal one third of trachea and bilateral bronchial trees that bled easily when touched. The cytological evaluation of the bronchial brushing specimens demonstrated clusters of small cuboidal cells consistent with an endometrial origin. Follow-up bronchoscopic examination at the end of the menstrual cycle revealed that the previous tracheobronchial lesions disappeared. The patient was treated with Gonadotropin-Releasing Hormone (GnRH) analogues and hormones including estrogen and progesterone therapy. Recurrent hemoptysis stopped following the medical treatment.

A randomized trial of smoking cessation. Medication versus motivation

OBJECTIVE

A prospective randomized study was undertaken to assess the effectiveness and side effect profiles of nicotine patch and bupropion therapies for smoking cessation.

METHODS

Three hundred and fifty patients were referred to our smoking cessation program in the Department of Pulmonary Diseases, Gaziantep University between September 2002 and July 2003. Of these, only 131 patients fulfilled the trial criteria. We randomized the patients into nicotine patch (n=50), bupropion (n=50) and control groups (n=31). Cases were followed up for 24 weeks. Questionnaires including the Fagerstrom test for nicotine dependence and Beck Depression Inventory were carried out at initial evaluation. Declaration of quitting and exhaled carbon monoxide level less than 10 ppm was accepted as success criteria.

RESULTS

Success rates were 26% for nicotine patch group, 26% for bupropion and 16% for control group at the end of the 24th week (p=0.56). Beck depression inventory scores did not differ significantly between the groups, however none of the cases with scores greater than 13 succeeded regardless of the group. Mean body weight at baseline and change at 6 months did not differ significantly between the groups. Sleep disturbance was significantly more common in nicotine patch and bupropion groups than the control group (p=0.008).

CONCLUSION

The present study reinforces the role of medical doctors and importance of close follow up in smoking cessation, and directed counseling is quite as effective as pharmacologic therapy and is the sole approach without any adverse effects.

Nocardia transvalensis infection in an immunocompetent patient reported from Turkey

Pulmonary nocardiosis is a rare infection mostly occurs in patients with immunosuppressive conditions. We report an immunocompetent case of pulmonary Nocardia transvalensis from Turkey, presented with bilateral pneumonia and bronchial dilatation treated six months with trimethoprim-sulfamethoxazole.

Horseshoe Lung Associated With Scimitar Syndrome and Pleural Lipoma

Horseshoe lung is a rare congenital anomaly characterized by the presence of unilateral pulmonary hypoplasia and a midline isthmus bridging the right and the left lung. Almost all cases of horseshoe lung are associated with the scimitar syndrome. The scimitar syndrome, sometimes called the congenital pulmonary venolobar syndrome, is a rare but well-described constellation of cardio-pulmonary anomalies. The characteristic abnormality is anomalous pulmonary venous return from a part of or the entire right lung to the inferior vena cava. We present a case of horseshoe lung associated with scimitar syndrome and pleural lipoma in an adult admitted for acute chest pain and chronic dyspnea.

[The results of patients follow up at Gaziantep Number II Dispensary of Tuberculosis Control in the year 2004]

In this study, the aim was to investigate the performance of number-II Dispensary of Tuberculous Control (DTC) in Gaziantep in 2004. The patients diagnosed to have tuberculosis between 2004 January 1st and 2004 December 31st were included. The patients registries were evaluated retrospectively. The mean age of the patients was 28.92+/-14.43 years (ranged between 1-68), 70.5% of the cases were male, and 72.5% of the cases were between 15-44 years old. Forty-two (82.3%) of the cases had the diagnosis of lung tuberculosis. 47% of them did not have any health insurance. The symptoms detected in the patients were cough, night sweats, sputum and hemoptysis respectively. There was no symptom registry in ten patients (19.6%). Sputum analysis to detect acid-fast bacilli (AFB) was done in 18 patients (19.6%). AFB was perfomed in 3.9% of the patients following two-months of therapy, and in 1.9% of the patients at the end of the therapy. Diagnostic tuberculous culture was performed in only one patient (1.9%). There was no tuberculous culture performed neither at the second month nor at the end of the therapy course. AFB was found to be positive in direct or concentrated sputum samples in eight (44.4%) of the patients. All the patients were evaluated with radiographies. The eritrocyte sedimentation rate was measured in 33.3%, 9.8%, and 15.6% of the patients before the therapy, at the end of the two months of therapy, and at the end of the therapy, respectively. The diagnosis was established with radiology clinical findings in 34 patients (66.6%). Directly observed therapy was performed in one patient (1.9%). The cure rate among smear positive patients was 12.5%, and the 100% of the patients were completed the therapy. There exists many problems with tuberculosis "warfare" and we believe the solution lies in DOTS.

Computed tomography features in malignant pleural mesothelioma and other commonly seen pleural diseases

OBJECTIVE

To investigate the computed tomography (CT) features of malignant pleural mesothelioma (MPM) cases, comparing them to those in other malignant and benign pleural diseases.

MATERIALS AND METHODS

We reviewed the CT findings of 215 patients; 99 with MPM, 39 with metastatic pleural disease (MPD), and 77 with benign pleural disease. The findings were evaluated in univariate and multivariate analysis for differentiation of pleural diseases.

RESULTS

In patients with MPM, the most common CT features were circumferential lung encasement by multiple nodules (28%); pleural thickening with irregular pleuropulmonary margins (26%); and pleural thickening with superimposed nodules (20%). In the majority (70%) of cases, there was rind-like extension of tumor on the pleural surfaces. In multivariate analysis, the CT findings of "rind-like pleural involvement", "mediastinal pleural involvement", and "pleural thickness more than 1 cm" were independent findings in differentiating MPM from MPD with the sensitivity/specificity values of 70/85, 85/67, and 59/82, respectively. "Rind-like pleural involvement", "mediastinal pleural involvement", "pleural nodularity" and "pleural thickness more than 1 cm" were independent findings for differentiation of malignant pleural diseases (MPM+MPD) from benign pleural disease with the sensitivity/specificity values of 54/95, 70/83, 38/96, and 47/64, respectively. Invasion of thoracic structures such as pericardium, chest wall, diaphragm, mediastinum, with pleural disease and nodular involvement of fissures, was detected infrequently; however, since these invasions were not seen in benign pleural diseases, it was concluded these invasions, if detected on a CT scan, directly suggested malignancy.

CONCLUSION

A patient has extremely high probability of malignant pleural disease if one or more of these CT findings are found and the possibility of MPM is high. These findings may be important for patients in bad state or patients who do not want any invasive biopsy procedures. It is also possible to identify cases with a low probability of malignant disease.

Gastroesophageal reflux in the patients with asthma

Thirty one patients with asthma (mean age was 44.4 10.7; range 18-63) were investigated for gastroesophageal reflux (GER). The patients were separated into two groups according to presence of reflux and/or nocturnal symptoms. 13 patients had one of the reflux and/or nocturnal asthma symptoms (Group 1), whereas 18 patients had none of them (Group 2). To assess GER patients underwent to scintigraphy with Tc99m. GER was determined 4 of 13 patients in group 1 (30,7 %) and 1 of 18 patients in group 2 (5,5 %). There was significant difference between the group 1 and group 2 in that respect (p < 0,001). The patients with established GER (5 patients) were given Omeprazole (a proton pomp inhibitor) 40 mg daily for 4 weeks following a 2 week placebo period. The patients recorded their daily and nocturnal symptoms of asthma, additional salbutamol use, morning and evening peak expiratory flow rates (PEFR) measurements in a daily chart during placebo and omeprazole treatment without changing their antiasthma treatment. Their PEFR, FEV1 values, daily and nocturnal symptoms and additional beta agonist use did not changed after omeprazole treatment except one. But their reflux symptoms (heartburn and regurgitation) were improved. As a consequence, we suggested that asthmatics which have some complaints of reflux should be searched for GER. Not the respiratory functions but GER symptoms can be improved w

The comparison of the effects of fluticasone propionate and budesonide on clinical indices and on bone mineral density in the asthmatic patients: a one year treatment study

BACKGROUND

it is well accepted that the inhaled administration of steroids is efficacious and has fewer side effects than the systemic use. Among them fluticasone propionate (FP) has been said to cause the similar antiasthma effect without unfavorable side effect at half the dose of the other ICS. The aim of the study was to compare the effects of FP 500 microg/day and budesonide (BUD) 800 microg/day as a pressurized metered dose inhaler (pMDI) for one year on clinical indices determined by FEV1 and diurnal variation of PEFR (peak expiratory flow rates) and on laboratory indices determined by serum cortisol and bone mineral density (BMD).

METHODS

a total of 30 nonsmoking mild to moderate asthmatic patients were recruited the study. 15 patients were given 800 microg/day BUD and 15 patients were given 500 microg/day FP as a pMDI. BMD measurements were done with dual energy X-ray absorbtiometry (DEXA) before and after the treatment at the lumbar area of the spine (L1-4) and left hip (trocanter major, neck of femur, intertrocanteric region and Ward's triangle). 10 patients of BUD group and 13 of FP group completed the study. After a year of treatment period, patients were compared on the basis of clinical indices (FEV1 and variability of PEFR), on serum cortisol levels and on BMD in both groups.

RESULTS

after the treatment, variability of PEFR (in BUD group p < 0,01, in FP group p < 0,001) and FEV1 (in BUD group p < 0,05, in FP group p < 0,05) were both improved in the groups. Serum cortisol levels and BMD of the patients in both groups were not changed significantly (p > 0,05).

CONCLUSIONS

the results suggested that FP 500 microg/d and BUD 800 microg/d as a pMDI results in a similar antiasthma effect without causing any adverse effect on BMD in mild and moderate asthmatics after one year treatment period.

Cisplatin, mitomycin, and interferon-alpha2a combination chemoimmunotherapy in the treatment of diffuse malignant pleural mesothelioma

STUDY OBJECTIVE

To investigate the therapeutic activity and toxicity of combination chemoimmunotherapy with cisplatin, mitomycin, and interferon (IFN)-alpha2a, by comparing the responses in a group of patients with diffuse malignant pleural mesothelioma (DMPM) to the responses in a control group of DMPM patients given supportive care alone.

DESIGN

Patients with histopathologically confirmed DMPM were evaluated for treatment with chemoimmunotherapy.

SETTING

After the initial evaluation, all patients received either chemoimmunotherapy or supportive care from the Osmangazi University Medical Faculty, Department of Chest Diseases.

PATIENTS

Forty-three patients with DMPM received chemoimmunotherapy until the end of the survey; 19 patients were given supportive therapy alone after refusing chemoimmunotherapy.

INTERVENTIONS

Drugs were administered according to the following schedule: IV cisplatin, 30 mg/m2 qd on days 1 and 2; IV mitomycin, 8 mg/m2 on day 1; and subcutaneous IFN-alpha2a, 4.5 million IU twice weekly. The courses were repeated every 4 weeks.

RESULTS

Overall, 232 chemoimmunotherapy cycles were administered. A total of 10 objective responses (ORs) in 43 patients (23%) were assessed, including 2 complete responses (5%), 4 partial responses, and 4 regressions. Seventeen patients had stable disease, and 16 patients had progression. The median survival time was 11.5 months for the 43 patients who received chemoimmunotherapy and 7.0 months for the 19 patients who received supportive therapy alone. The difference in survival times between the chemoimmunotherapy and supportive therapy groups was not significant. However, the median survival time for the patients who had OR was 21.3 months, which is significantly longer than that of the patients who received supportive care alone and that of patients with progressive disease (6 months). The toxicities associated with the treatment schedule of this study were, for the most part, tolerable.

CONCLUSIONS

The drug combination used in this study is moderately effective and well tolerated in patients with DMPM, especially in those who responded to the treatment.

Environmental asbestos exposure and malignant pleural mesothelioma

Asbestos-related benign and malignant pleural diseases are endemic in some rural parts of central Turkey because of environmental exposure to asbestos fibres. We report here epidemiological data on 113 patients with diffuse malignant pleural mesothelioma (DMPM) diagnosed in our clinic in Eskişehir, located in central Turkey. Of the 113 patients, 59 were men and 54 women (male:female ratio = 1). Ninety-seven patients (86%) had non-occupational asbestos exposure; all were living in villages. Their mean age was 56 years. As the patients had been exposed to asbestos from birth, the latency period was equivalent to the age of the patients. Twenty-eight patients (29%) had lived in villages their entire lives. The other 69 (71%) had been born in a village but migrated to the city or had given up white-soil usage for various reasons. The mean exposure time was 55 years for those with a long exposure period and 25 years for those with a short exposure period, but there was no significant difference between the age of the disease appearance for both groups (55 and 56 years, respectively). Thus, the latency time of mesothelioma due to environmental exposure to asbestos was longer than that due to occupational exposure, but independent of the length of exposure. Soil samples from 67 villages were analysed, comprising a population of 10,120 villagers. Tremolite and some other types of asbestos were found. In conclusion, DMPM in our region is due to mainly to environmental exposure to asbestos. The risk is substantial as a large proportion of the villagers are exposed. After smoking, asbestos exposure is one of the most serious health hazards in our rural population.

Misoprostol has no favorable effect on bronchial hyperresponsiveness in mild asthmatics

Misoprostol, a synthetic prostaglandin E1 analogue, has been reported to have antibronchoconstricive and antiinflammatory effects in animal studies. We investigated the effect of misoprostol on FEV1 and bronchial hyperresponsiveness (BHR) to histamine in mildly asthmatics. 14 mildly asthmatic patients were given 400 mg/day oral misoprostol. Four patients had to left the study either due to the side effects. The remaining 10 patients (all women and mean age was 33.2 +/- 3.3) underwent the histamine challenge test before and after the treatment with misoprostol. Mean values of FEV1 obtained before and after the treatment were as follows respectively: 2.79 +/- 0.17 L; 2.78 +/- 0.18 L. Mean log PC20 values were as follows respectively: 0.60 +/- 0.23 mg/ml; 0.60 +/- 0.14 mg/ml. There was no difference either in FEV1 and log PC20 values before and after the treatment with misoprostol (p > 0.05). As a result administered misoprostol has no favorable effect on expiratory flow rates and BHR in asthmatic patients.

Lymphocyte subtypes in asthma: relationship with the clinical status and bronchial hyperreactivity

To study the role of T lymphocytes in asthma and its relationship with clinical severity, atopic status and bronchial hyperreactivity (BHR), we have examined T cell populations in peripheral blood of 32 stable asthmatic (18 non atopic, 14 atopic) and 10 non atopic-non asthmatic person using flow cytometry. BHR was determined with histamine challenge test. The percentages of CD4+, CD8+ T lymphocytes, CD4/CD8 ratios, T cell activation markers (IL-2R, CD25; HLA-DR) were not different from control (p > 0.05). The percentage of CD16+ CD56+ cells were higher in peripheral blood of asthmatics (15.5% versus 9.3% p < 0.05). In the asthmatic group, there was inverse correlation between BHR and CD4/CD8 ratio (p < 0.05). The percentages of CD5+ T lymphocytes bearing activation marker CD25 significantly higher in severely asthmatics when compared with mild asthmatics (13.2 +/- 2.0 versus 7.8 +/- 1.1% p < 0.05). These results suggest that natural killer activity is increased in the asthmatics, severely asthmatics have more T lymphocytes bearing activation marker CD25 and BHR would be related with CD4/CD8 ratio rather than the other T lymphocytes subpopulations in peripheral blood.