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Eurasian J Pulmonol: 18 (2)
Volume: 18  Issue: 2 - August 2016
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2.Therapeutic options for bronchiolitis obliterans syndrome after lung transplantation
Nina Hangartner, Macé Matthew Schuurmans, Christian Murer, Christian Benden, Lars Christian Huber
doi: 10.5152/ejp.2016.92486  Pages 63 - 69
The development of chronic lung allograft dysfunction (CLAD) is one of the major obstacles following lung transplantation and limits patients’ long-term outcome. Within the group of emerging CLAD phenotypes, bronchiolitis obliterans syndrome is the most common form and observed in up to 75% of lung transplant recipients 10 years after transplantation. Therapeutic options to address BOS are limited and, at our center, include modification of immunosuppression, immunomodulation using macrolide antibiotics, the use of statins, leukotriene receptor antagonists, and extracorporeal photopheresis. The evidence for most of these therapy options is derived from case reports or small, descriptive studies, whereas controlled trials are yet to be conducted. In the context of an illustrative case report, we review hereby the current literature regarding these different treatment options.

3.Review of the Proposals in the Forthcoming 8th TNM Classification of Lung Cancer
Deniz Köksal, Funda Aksu
doi: 10.5152/ejp.2016.87004  Pages 70 - 75
Staging of lung cancer is a key factor for both prognostication and management of patients. Thus, there is a need for an accurate, uncomplicated, easily reproducible staging system. The database of the 8th TNM (T: Tumor, N: Node, M: Metastasis) classification is based on information gathered from 94,708 patients who received diagnoses of lung cancer between 1999 and 2010, originating from 35 sources in 16 countries. Data analysis was performed in 2013–2014 regarding proposals put forward for the 8th edition and was published in the Journal of Thoracic Oncology. It is thought that the 8th edition will be used in 2017. In this edition, tumor diameter is more important and each centimeter counts (T1a: ≤1 cm, T1b: >1 cm but ≤2 cm, T1c: >2 cm but ≤3 cm, T2a: >3 cm but ≤4 cm, T2b: >4 cm but ≤5 cm, T3: >5 cm but ≤7 cm, and T4: >7 cm). There are changes in some T descriptors such as main bronchus involvement (T2), total atelectasis/pneumonitis (T2), involvement of diaphragm (T4), and mediastinal pleural invasion (not used as T descriptor). Current N staging is still valid; however, there are clues for the importance of the abundance of nodal involvement. Three metastatic groups are defined: M1a (contralateral/bilateral tumor nodules, pleural/pericardial nodules or effusion), M1b (single metastatic lesion in one organ), and M1c (multiple metastasis in either single or multiple organs). More stage groupings demonstrating good prognostic categories are proposed. These changes do not have much implication on treatment. The proposed taxonomic changes do not affect therapeutic modalities. However, care should be taken to follow up for small pulmonary nodules.

4.Differentiating Pleural Effusions: Criteria Based on Pleural Fluid Cholesterol
Srinath Dhandapani, Sivakumar Reddy, Rajalakshmi Rajagopalan
doi: 10.5152/ejp.2016.88597  Pages 76 - 79
Objective: To assess the efficacy of pleural fluid cholesterol in differentiating transudates and exudates as compared with Light’s criteria.
Methods: Patients with pleural effusion during a 6-month period were enrolled in the study and underwent thoracentesis. Pleural fluid was analyzed for the levels of protein, lactate dehydrogenase (LDH), and cholesterol. Etiological diagnosis, which was established after considering clinical and biochemical factors, was the gold standard for comparison. Cut-off values for pleural fluid cholesterol were taken as 60 mg/dL and 45 mg/dL.
Results: A total of 53 patients were included for final analysis. Of them, 19 were with transudates and 34 with exudates in their pleural fluids. The sensitivity, specificity, positive predictive value, and negative predictive value of the pleural fluid cholesterol (cut-off >45 mg/dL) were 97.06%, 94.74%, 97.06%, and 94.74%, respectively, for identifying exudates. These values were differentiating better than those obtained by Light’s criteria for pleural fluid cholesterol (cut-off >60 mg/dL) (p<0.0001). Combining pleural fluid protein with pleural fluid cholesterol (>45 mg/dL) gave a higher specificity (100%) and positive predictive value (100%) but a lower sensitivity (82.93%) and negative predictive value (63.16%).
Conclusion: Pleural fluid cholesterol is better than Light’s criteria for the differentiation of transudates and exudates and is less cumbersome as it does not require a simultaneous blood sampling. Cut-off value of pleural fluid cholesterol for differentiating transudates and exudates should be 45 mg/dL. Further studies are warranted to assess the efficacy of the combination of pleural fluid protein and cholesterol as criteria for classifying effusions.

5.Two-Years Follow-up Results of a Smoking Cessation Clinic in a State Hospital
Sami Deniz, Jülide Çeldir Emre, Özer Özdemir, Ayşegül Baysak
doi: 10.5152/ejp.2016.69885  Pages 80 - 84
Objective: The primary aim of the present study was to evaluate the data and success of a smoking cessation clinic in a secondary state hospital. Secondarily, the study aimed to compare the cessation rates of patients using varenicline and bupropion.
Methods: A total of 251 patients, admitted to our smoking cessation clinic were retrospectively evaluated. The smoking cessation clinic was run one day every week and included a 35-min presentation on smoking cessation and face-to-face interviews with every patient who attended the clinic. Monthly control visits were conducted, and after 2 years all the patients were asked about their smoking status via a phone call.
Results: A total of 152 out of the 251 patients, namely those who were successfully contacted, were included in the study. The average age of the study population was 46.2±11.2 (18–69), and 81 (53.3%) were female. The average nicotine dependence level was 5.8±2.3. The nicotine dependence levels and the amount of current cigarette consumption in one day were higher in the varenicline group (p=0.003 and p=0.002, respectively), whereas the duration of treatment was lower (p=0.009). Among all the patients, the average smoking cessation rate was 61.2% in 6 months, 34.2% in 12 months, 18.4% in 18 months, and 5.3% in 24 months. There were no differences in smoking cessation rates between the varenicline and bupropion groups (p>0.05).
Conclusion: An effective success in smoking cessation was observed with the combined use of behavioral and pharmacological modalities. Intensive behavioral interventions and treatment and follow up for longer durations, particularly for patients with risk factors for relapse, can increase the success of smoking cessation clinics.

6.Effect of Continuous Positive Airway Pressure Treatment on Mean Platelet Volume and Platelet Distribution Width in Patients with Sleep Apnea Syndrome
Mustafa Çörtük, Gökçe Şimşek, Kemal Kiraz, Süheyl Haytoğlu, Burcak Zitouni, Nuray Bayar Muluk, Osman Kürşat Arıkan
doi: 10.5152/ejp.2016.84803  Pages 85 - 89
Objective: Obstructive sleep apnea (OSA) syndrome is a common disorder that can cause hypercoagulation. Mean platelet volume (MPV) and platelet distribution width (PDW) are associated with hypercoagulability. This study aimed to investigate whether MPV and PDW values change in patients with OSA who were treated with continuous positive airway pressure (CPAP) device.
Methods: A total of 43 adult patients with OSA who were treated with CPAP were included in this retrospective study. Patients who underwent CPAP treatment for <5 days/week and <4 h/day were excluded. Blood parameters, including MPV and PDW, were recorded before CPAP treatment and at the third month of CPAP treatment. All patients underwent polysomnographic evaluation with full night polysomnography and in the second night CPAP titration was performed together with full night polysomnography and MPV and PDW values were statistically compared before and after CPAP treatment.
Results: Apnea hypopnea index was significantly reduced, whereas oxygen saturation was significantly increased at CPAP titration night (p<0.001). The third month of CPAP treatment resulted in significantly low PDW (p=0.004) values, but MPV values did not change.
Conclusion: PDW value at the third month of CPAP treatment revealed a significant improvement compared with the values before treatment; moreover, no change was observed in MPV values. It was concluded that in patients with OSA who were treated with CPAP, activation of platelets may result in recovery.

7.Retrospective Analysis of Antibiotic Susceptibility Patterns of Respiratory Isolates of Pseudomonas Aeruginosa in a Chest Diseases Public Hospital
Abdullah Şimşek, Ilhami Yapıcı, Ekrem Temiz, Ibrahim Ocak, Mustafa Kolsuz
doi: 10.5152/ejp.2016.41636  Pages 90 - 95
Objective: Multidrug resistance is a major problem of Pseudomonas aeruginosa strains. We aimed to determine the level of resistance to the antipseudomonal antibiotics, the change in the rates of antibiotic resistance over the years, and mortality rate during hospital stay.
Methods: The microbiology database of P. aeruginosa isolated from 3708 sputum and 485 bronchial lavage samples at Chest Diseases Public Hospital from January 2009 to December 2013 was retrospectively reviewed. Imipenem, amikacin, tobramycin, ciprofloxacin, piperacillin, piperacillin/tazobactam ceftazidime, and cefepime resistance rates of P. aeruginosa strains were determined. Antimicrobial susceptibility was determined by the disk diffusion method, according to the Clinical Laboratory Standards Institute (CLSI) guidelines. P. aeruginosa was defined as resistant (resistance to at least one of the antipseudomonal antibiotics), and multidrug resistant (MDR) (resistance to three or more drugs of following classes: β-lactam, carbapenem, aminoglycoside, and fluoroquinolone).
Results: Five hundred and five P. aeruginosa isolates were tested. The antibiotic resistance rates were as follows; cefepime (26.7%), ceftazidime (23.2%), piperacillin (22.2%), imipenem (21.8%), piperacillin/tazobactam (19.2%), ciprofloxacin (17.4%), tobramycin (11.9%), and amikacin (7.3%). When compared 2009 and 2013, statistically significant reduction was observed in resistance rates to ciprofloxacin, amikacin, and cefepime antibiotics. Among 505 strains, 12.1% were designated as being MDR. Out of 505 patients investigated, 34 (6.7%) died during the hospital stay.
Conclusion: The clinical significance of these findings is important in the selection of appropriate empirical treatment of serious P. aeruginosa infections.

8.Approaches of Physicians for the Diagnosis and Treatment of Pulmonary Thromboembolism: A Questionnaire Study
Ceyda Anar, Oğuzhan Okutan, Bülent Altınsoy, Savaş Özsu, Oğuz Uzun
doi: 10.5152/ejp.2016.40085  Pages 96 - 103
Objective: We aimed to demonstrate the approaches of physicians with a questionnaire toward the patients with pulmonary thromboembolism (PTE) in our country.
Methods: An invitation letter including a questionnaire with 28 questions to assess the approaches they prefer in the patients with PTE and the capabilities of the departments they work at and a link for the questionnaire was directed to the mail groups of chest diseases specialists. Responses of the physicians who participated in the questionnaire were reviewed.
Results: The examinations used to diagnose PTE such as D-dimer, troponin, echocardiographic Doppler ultrasonography and multidetector computed tomography (CT) have been performed in 94% of the institutions, ventilation/perfusion scintigraphy, MRI and pulmonary angiography examinations were performed in 50% of the instututions. While D-dimer test was performed in 73.2% of the institutions by quantitative ELISA; in 15.7% of them it was semiquantitative and in 11.6% of the instutitions it was performed by latex agglutination. 81% of physicians were seen to be using clinical probability scoring systems and most commonly used scoring method was seen to be Wells scoring with a rate of 90%. According to the simplified PESI score, 61.5% of the physicians reported to prefer outpatient treatment. In non-massive and submassive pulmonary thromboemboli patients, 86.2% of the physicians reported to prefer thr low molecular weight heparin (LMWH) treatment; vitamin K antagonist in maintenance treatment was also the most commonly resorted drug with a percentage of 84.9.
Conclusion: The absence of the examinations used in the diagnosis and treatment of PTE in most institutions and difficulty to reach the available examinations at all hours of the day were significant facts. Especially; lack of access to high-sensitivity D-dimer test, bedside echocardiography used to assess right ventricular dysfunction, troponin and NT-proBNP makes us think about low adaptation to guidelines.

9.Idiopathic Chronic Eosinophilic Pneumonia: Retrospective Analysis of 17 Cases from a Single Center in Turkey
Sibel Arınç, Umut Sabri Kasapoğlu, Sinem Güngör, Meltem Ağca, Murat Yalçınsoy, Ilim Irmak, Pınar Güney, Murat Kavas, Hatice Türker
doi: 10.5152/ejp.2016.29291  Pages 104 - 110
Objective: Idiopathic chronic eosinophilic pneumonia (ICEP) is a rare eosinophilic lung disorder with an unknown etiology and is characterized by subacute or chronic respiratory and general symptoms, alveolar and/or peripheral eosinophilia, and the accumulation of eosinophils in the lungs. We aimed to present diagnostic test results and follow-up outcomes of 17 patients who were diagnosed with ICEP in our hospital in light of literature.
Methods: Between 2008 and 2013, we examined 17 cases of ICEP. We evaluated clinical and laboratory findings together with the long-term follow-up data.
Results: The patients had a mean age of 40.8 years at presentation, and the female/male ratio was 0.8. The most common symptoms were cough (94%), shortness of breath (76%), and high fever (35%). Bronchoalveolar lavage eosinophil percentages of the patients ranged from 3% to 80%. Nine (53%) patients experienced recurrence. Six patients were maintained on low dose steroid due to repeating relapses. Among these patients, 7 (77.7%) had a total IgE level of above 500/IU/mL.
Conclusion: Relapses are common in ICEP after the withdrawal of corticosteroid treatment or during dose reduction. We point out the importance of the close monitoring of patients for identifying relapse. A higher total IgE level during diagnosis may serve as a predictor of recurrence.

10.Evaluating Fluoroquinolone Use in Patients Admitted to the Tuberculosis Outpatient Clinic
Sinem İliaz, Seda Tural Önür, Mediha Gönenç Ortaköylü
doi: 10.5152/ejp.2016.63935  Pages 111 - 115
Objective: Inelaborate use of new quinolones with strong anti-tuberculosis (TB) activity leads to difficulty in diagnosis and more importantly, quinolone-resistant Mycobacterium tuberculosis. We aimed to determine the frequency of quinolone use in patients who were referred to our hospital for suspected TB and to evaluate the association between quinolone use and different clinical laboratory parameters.
Methods: Between November 15 and December 15, 2013, all patients who were admitted to the TB outpatient clinic with no previous diagnosis of TB were included in this study. Demographic and clinical laboratory findings and history of antibiotic use were recorded. Patients’ quinolone use were questioned by showing fluoroquinolone antibiotic boxes’ photographs available on the market. The departments of the doctors who prescribed quinolones were recorded.
Results: The mean age of 179 patients included in the study was 37±16 (15–89) years. Among these, 113 patients (63.1%) were male. Seventy five patients (41.9%) were diagnosed as tuberculosis according to the clinical-radiological and/or bacteriological findings. Of 179 patients, 58.1% (n=104) had been prescribed antibiotics for current complaints before referral to our clinic. Sixteen patients (15%) had been recommended fluoroquinolones. Fluoroquinolones were prescribed by seven internal medicine specialists, five pulmonologists, three emergency medicine specialists, and one family medicine practitioner. Among 16 fluoroquinolones prescribed, nine were moxifloxacin, four were levofloxacin, and three were gemifloxacin. Quinolone use revealed a significant inverse relationship only with the presence of hemoptysis (p=0.04).
Conclusion: Besides increased educational activities regarding the rational use of antibiotics in recent years, the quinolone group of antibiotics is still prescribed for suspected TB cases. To avoid quinolone-resistant M. tuberculosis strains, further education is required.

11.A Rare Case in Turkey: Pulmonary Histoplasmosis
Ufuk Turhan, Mehmet Aydoğan, Tuncer Özkısa, Yıldırım Karslıoğlu, Seyfettin Gümüş
doi: 10.5152/ejp.2016.96720  Pages 116 - 118
Histoplasma capsulatum, which is the causative agent of histoplasmosis, appears in the soil globally. There are a limited number of histoplasmosis cases reported from Turkey. In this article, we present a patient with Histoplasma pneumonia developed during corticosteroid treatment. A 70-year-old female with invasive ductal carcinoma was admitted to our department with shortness of breath, cough, and weakness. Her clinical and radiological findings were compatible with radiation pneumonitis. Computed tomography of thorax (Thoracic CT) revealed scattered and patchy areas of consolidation, ground-glass opacities, and ground-glass density nodules in all lobes of the lungs. Transthoracic tru-cut biopsy was performed under CT guidance. Histopathological examination showed microorganisms morphologically consistent with Histoplasma became apparent with silver stain in the alveolar lumen. Patient was treated with itraconazole for 6 months. She responded well to the treatment with a complete clinical and radiological regression. Histoplasmosis is a worldwide disease. It should be noted that pulmonary histoplasmosis could be seen in our country. Because of this, pulmonary histoplasmosis should be kept in mind in immunocompromised patients as an opportunistic pulmonary infection in our country.

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