Tüm dünyada önemli bir sorun olan tüberkülozun görülme sýklýðý yaþla birlikte artmakta, tüberkülin testi reaktivitesi ise azalma göstermektedir. Ýlimizdeki huzurevinde yaþayan yaþlýlarda tüberküloz enfeksiyon prevalansýný bulmak, tüberkülin reaktivitesindeki deðiþiklikleri saptamak amacýyla çalýþmayý yaptýk. 137'si huzurevinde yaþayan (Grup I), 50'si orada çalýþan (Grup II) olmak üzere toplam 187 kiþiye tüberkülin deri testi yapýldý. Endurasyon çapý 10mm ve üzeri pozitif kabul edildi. Ayrýca olgularýn mikrofilmleri temin edildi. Erkeklerde pozitiþik oraný (%84.2), kadýnlardakinden ( %67.4) anlamlý derecede yüksek idi (p=0.007). Grup I'de yaþ ort. 72.6±9.8 yýl, Grup II'de 34.5±6.3 yýl idi. Tüberkülin deri testi Grup I'de 97 (%70.8), Grup II'de 46 kiþide (%92) pozitif bulundu (p=0.002). Ortalama tüberkülin testi endurasyon çapý Grup I'de 17.66±5.65 mm, Grup II'de 13.96±9.03 mm olarak hesaplandý, aradaki fark istatistiksel olarak anlamlý idi (p=0.001). Ortalama endurasyon çapý Grup I'de erkekler için 15.53±7.6 mm, kadýnlar için 11.81±10.38 mm idi (p= 0.023). Grup I ve II birlikte deðerlendirildiðinde yaþ ilerledikçe çapýn küçüldüðü (50-59 yaþ; 24.6±3.5 mm, 80-89 yaþ; 12.94±8.8 mm) (p=0.007, r= -0.195), sadece Grup I'de istatistiksel olarak anlamlý olmasa da, çapýn yaþlanmayla birlikte yine küçüldüðü görüldü Sonuç olarak tüberkülin deri testi reaktivitesi yaþlanma ile birlikte belirgin azalma göstermektedir. Kapalý ve kalabalýk yerlerde yaþayan yaþlýlarda bu testin yapýlmasý zaten nosocomial tüberküloz ile karþý karþýya bulunan bu kiþilerin enfeksiyon durumlarýný göstermesi açýsýndan yararlý olabilir.

The incidence of tuberculosis, an important problem in all the world, increases with age but the reactivity of tuberculin test decreases. We aimed in this study, to find out the prevalence of tuberculosis infection among old people leaving in a covered place like nursing home and to determine tuberculin reactivity alternations with aging. Tuberculin skin test was carried out on total 187 persons, 137 residents ( Group I) and 50 workers (Group II). 10mm or greater of induration diameter was accepted as positive result. The positivity ratio was 84.2 % for males and 67.4 % for females, and the difference between was significant (p=0.007). The mean age was 76.2 ± 9.8 years in group I and 34.5 ± 6.3 years in group II. Tuberculin skin test was positive on 97 persons in group I (70.8 %) and 46 in group II (92 %) (p=0.002). The mean induration diameter was 17.66 ± 5.65 mm in group I and 13.96 ± 9.03 mm in group II, and the difference was statistically significant (p=0.001). Also, the diameter in group I was 15.53 ± 7.6 mm for males, and 11.81 ± 10.38 for females (p=0.023). When group I and II evaluated together, it was seen that the diameter diminished with aging (50-59 ages 24.6±3.5mm, 80-89ages;12.94±8.8 mm) (p=0.007, r= -0.195) and again only in group I the diameter diminished with aging although it is not statisticallly significant. In conclusion carying out of tuberculin skin test (especially two-step ) on elderly persons living in closed enviroments such as nursing homes may be useful in showing tuberculosis infection. It must be hold in mind that the humans with weaning immune system of various reasons are face to face with nosocomial tuberculosis.

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Dünya çapýnda önemli bir saðlýk sorunu olan tüberkülozun (tbc) kesin taný yöntemi olan kültürün 45 gün gibi uzun bir sürede sonuç vermesi tedaviye baþlamayý geciktirmektedir. Erken taný yöntemi olan, balgam veya mide açlýk suyunda direk basil aranmasýna alternatif yöntemler araþtýrýlmaktadýr. A60 antijeni mikobakterinin sitoplazmasýnda bulunan ve yüksek oranda immun cevap oluþturan bir antijen olup serolojik tanýda yararlý olacaðý düþünülmektedir. 21 aktif akciðer tbc'li, 20 inaktif akciðer tbc'li ve 22 nonspesifik akciðer enfeksiyonu olan (kontrol) toplam 63 olgunun serumunda A60 antijenine karþý meydana gelen IgG ve IgM düzeyleri ölçüldü. Farklý cut-off deðerlerine göre (225 Ü ve 254 Ü) IgG için sensitivite sýrasýyla %80.95 ve %71.43, spesifitesi sýrasýyla %81.82 ve %86.37 olarak bulundu. Sensitivite ve spesifite IgM için %28.57, %86.37, direk yayma için %66.66 ve %100 olarak bulundu. IgG'nin sensitivitesi direkt yaymadan daha yüksek olmakla birlikte spesifitesi daha düþüktü. IgG'nin farklý cut-off deðerlerine raðmen inaktif akciðer tbc'lilerde ve kontrol grubunda da pozitif çýkmasý testin tanýdaki deðerini azaltmaktadýr. IgM'in ise hem sensitivitesi hemde spesifitesi direkt yaymadan daha düþük olarak bulundu. Sonuç olarak IgG düzeyinin aktif tbc tanýsýnda tek baþýna yetersiz olacaðý, yardýmcý bir yöntem olabileceði, tüberkülin deri testi gibi yoruma açýk olduðu, diðer bulgularla beraber deðerlendirilmesi gerektiði düþünülmektedir.

Tuberculosis is still an important problem in the world. Because of the sputum culture which results in 45 day the certain diagnosis of tuberculosis can be delayed. Alternative methods for early diagnosis (the recovery of tubercle basilli in sputum or hungry stomach liquid) have been investigated. A60 antigen is present in the cytoplasma of mycobacterium and causes highly immune response, because of this, it is thought that A60 antigen can be useful for serologic diagnosis. The IgG and IgM levels against serum A60 antigen were measured in 21 active and, 20 inactive pulmonary tuberculosis and 22 nonspesific pulmonary infection (totaly 63 cases). Sensitivity and spesifity accoding to different cut-off levels (225U and 254U) were found 80.95%, 71.43% and 81.82%, 86.37% respectively for IgG. Sensitivity and spesifity were found 28.57% and 86.36% respectively for IgM, 66.6% and 100% for direct sputum smear. The sensitivity of IgG was higher than direct sputum sample but its spesifities were more lower. Although different cut-off levels the IgG test was positive in inactive tuberculosis cases and control group, result of the value of the test becomes decreased. The spesifity and the sensitivity of IgM were lower than direct sputum smear. In conclusion, we think that in the diagnosis of active tuberculosis alone the level of IgG can not be enough but it can be a helper method, it is controversial as tuberculin skin test, it must be evaluated with the other findings.

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Kronik solunum yetersizliði geliþmiþ olan KOAH olgularýnda uzun süreli oksijen tedavisi(USOT) yaþam kalitesini arttýran ve yaþam süresini uzattýðý gösterilen tek tedavi yöntemidir. Tedavinin etkinliði için günde en az 15 saat oksijen alýnmasý gerekmektedir. Çalýþmamýzda USOT endikasyonunun uzlaþý raporlarýna uygunluðunu, hastalarýn tedaviye uyumlarýný ve uyumu etkileyen faktörleri deðerlendirdik. Tedavinin AKG, spirometri, dispne skoru, akut atak, hastane ve yoðun bakýma yatýþ sayýlarýna olan etkilerini takip ettik. Cerrahpaþa Týp Fakültesi Göðüs Hastalýklarý Anabilim Dalý tarafýndan USOT önerilen 78 olgunun saðlýk kurulu raporlarýnda endikasyonlarý inceledik. KOAH polikliniðinde takip edilen, oksijen konsantratörü kullanan, 20 erkek, 9 kadýn ve yaþ ortalamasý 64±8 (45-75) yýl olan 29 olgu takibe alýndý. Tedavi baþlangýcýnda hastalarýn demografik özellikleri, dispne skoru, solunum fonksiyon parametreleri, yýllýk akut atak, hastane ve yoðun bakýma yatýþ sayýlarý kaydedildi. USOT endikasyonlarýnda uzlaþý raporlarýna uygunluk %95 olarak saptandý. Konsantratör kullanmakta olan ve yeni baþlayan 29 olgunun 10±2 ay takibi sonucu PaO2'nin 51±6'dan 58±9 mmHg'ya (p=0.001), Sat O2%'nin 85±5'den 89±4'e (p<0.001) yükseldiði, PaCO2'nin 48±7'den 44±7 mmHg'ya (p=0.02) düþtüðü saptandý. USOT sonrasý dispne skoru 1. yýlda azaldý (p=0.05). Tüm olgularda yýllýk toplam akut atak sayýsý 39'dan 6'ya, hastaneye yatýþ 37'den 6'ya (p<0.001) ve yoðun bakýma yatýþ sayýsý 3'den 0'a (p=0.03) düþtü. Tedaviye uyum oraný %31 olarak saptandý. Etkin tedavi alanlar, diðerlerine göre daha hipoksik, daha hiperkapnik, dispne skoru yüksek ve FEV1/FVC deðeri daha düþük olan hastalardý. USOT PaO2'yi arttýrmakta, PaCO2'yi, akut atak sayýsýný, hastane ve yoðun bakýma yatýþ sayýsýný azaltmaktadýr. Tedaviye uyumu hastalarýn kiþisel özellikleri etkilememekte, hastalýðýn aðýrlýk derecesi, semptomlarýn þiddeti arttýkça uyum artmaktadýr.

Long-term oxygen therapy (LTOT) is the only mode of treatment which increases the quality of life and prolongs life time expectancy in chronic obstructive pulmonary disease(COPD) patients with chronic respiratory failure. Minimum 15 hours/day oxygen use is necessary for treatment efficacy. In our study we evaluated the appropriateness of LTOT indications to concensus reports, the compliance of patients to treatment and the factors effecting compliance. The effects of treatment on arterial blood gas, spirometry, dyspnea score, acute attack, hospitalization and intensive care need were observed. We evaluated the LTOT indications of 78 patients from Cerrahpafla Medical Faculty Department of Pulmonology. 29 patients (20 male, 9 female) with median age of 64±8, followed-up from the COPD out-patient clinic and using oxygen concentrator were recruited in the study. The demographic features of the patients, dyspnea score, lung function test parameters, annual number of acute attacks, hospital and intensive care support needs were recorded. The appropriateness of LTOT indications to consensus reports was found as 95%. 29 patients consisted of patients already using concentrator and new users. The patients were observed for 10± 2 months. PaO2 and the oxygen saturation percentages increased from 51±6 to 58±9 mmHg (p=0,001), and from 85±5 to 89 ±4 (p<0,001) respectively. PaCO2 showed a decrease from 48±7 to 44±7 mmHg (p=0,02), annual acute attacks from 39 to 6, hospitalization from 37 to 6 (p<0,001) and intensive care hospitalization from 3 to 0 (p=0,03) respectively, the results being statistically significant. The dyspnea score significantly decreased during the first year of LTOT use (p<0,05). The compliance to treatment was 31% and this group consisted of patients with low FEV1/ FVC, high dyspnea score and they were more hypoxic and hypercapnic than the non-compliant patients. The results show that LTOT increases PaO2 and decreases PaCO2, acute attacks, hospitalization and intensive care need. Compliance to treatment does not depend on the personal characteristics of the patients rather increases with the severity of disease and symptoms. We believe with patient education and closer follow-up, the compliance of our patients to treatment will be increased.

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Bronþektazili hastalar sýklýkla hospitalizasyon gerektirmekte, morbitite ve mortalite açýsýndan yüksek risk taþýmaktadýr. Bu çalýþmada, 2000 yýlýnda Atatürk Göðüs Hastalýklarý ve Göðüs Cerrahisi Eðitim ve Araþtýrma Hastanesinde bronþektazi tanýsýyla izlenen 138 olgu retrospektif olarak klinik, bakteriyolojik, radyolojik özellikleri ve tedavi yöntemleri açýsýndan incelenmiþtir. Hastalarýn yaþ ortalamasý 51.7± 12.8 idi. En sýk gözlenen semptomlar olarak nefes darlýðý(%70.4) ve öksürük (%54.3) tespit edildi. Bronþektazili olgularýn 68'i (%48) bilateraldi. Predispoze faktör olarak en fazla tüberküloz (%25.3) ve çocukluk çaðý enfeksiyonlarý(%21) saptandý. Olgularýn 39'unda (%28.2) bronþektaziye baðlý komplikasyonlar bulundu ve en sýk gözlenen komplikasyon tekrarlayan pnömöni idi. Otuz bir olguya (% 22.5) cerrahi tedavi uygulanýrken, geriye kalan 107 olguya (%77.5) medikal tedavi verilmiþtir. Cerrahi rezeksiyon olarak en sýk sol alt lobektomi ve lingulektomi (%19.2) ve sað alt lobektomi (% 19.2) uygulanmýþtýr. Bronþektazi ülkemizde halen ciddi bir sorundur.Çocukluk çaðý enfeksiyonlarý ve tüberkülozun yeterli tedavisi ve etkin aþýlama programlarý ile bronþektazi insidansýnda azalma gözlenebilir.

Patients with bronchiectasis have a high risk of morbidity and mortality with a prolonged hospitalization.In this study, bacteriologic, radiologic findings , predisposition factors and treatment of 138 patients who were treated in Atatürk Chest Disease and Chest Surgery Center in 2000 are examined retrospectively Median age was 51.7±12.8 years. The most observed symptoms were dyspne(70.4%) and cough (54.3 %). In 68 (49.2 %) of cases bronchiectasis were bilateral. Tuberculosis (25.3 %) and childhood infections(21%) were the most common predisposing factors.In 39 (28.2 % ) of cases, there were complications related to bronchiectasis. The most seen complication was recurrent pneumonie (15%). Surgery was applied to 31 (22 %) of cases while the rest of the patients were medically treated. The most applied surgical resections were left basal lobectomy- lingulectomy (19.2%) and right basal lobectomy (19.2%). Bronchiectasis is still a serious matter in our country. By the sufficient treatment of childhood infections tuberculosis and effective vaccinotion programs, decrease of the incidence of bronchiectasis can be observed.

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Mediastinoskopi akciðer kanseri evrelemesinde kullanýldýðý gibi sarkoidoz, lenfoma ve mediastinal tümör gibi intratorasik hastalýklarýn tanýsý için de kullanýlabilen güvenilir, invazif bir yöntemdir. Bu çalýþmada amacýmýz, kliniðimizde mediastinoskopi uygulanan olgularda tekniðin uygunluðunun araþtýrýlmasýdýr. Mart 1993 - Aralýk 2000 yýllarý arasýnda merkezimizde 494'ü (%80.9) evreleme amaçlý, 116'sý (%19.01) tanýsal amaçlý olmak üzere 610 mediastinoskopi uygulanmýþtýr. Standard mediastinoskopiye ek olarak evreleme amaçlý olgularýn 35'ine (%7.08), tanýsal amaçlý olgularýn ise 7 'sine (%6.03) ekstended mediastinoskopi uygulandý. Evreleme amaçlý mediastinoskopi yapýlan 494 küçük hücreli dýþý akciðer karsinoma olgu serisinin 381'i (% 77.1 ) N0, 113'ü ise (%22.8 ) N2 hastalýk olarak belirlendi. N2 hastalýðý olan 113 olgunun 32'sinde N3 hastalýðý mevcuttu. Mediastinoskopide N0 tespit edilip torakotomi sonrasý N2 olarak belirlenen olgu sayýsý 40 (%10.4) dýr. Çalýþmamýzda mediastinoskopinin sensitivitesi % 74, spesifitesi % 100, pozitif prediktif deðeri % 100, negatif prediktif deðer % 88 ve doðruluk oraný % 91 olarak belirlenmiþtir. Major komplikasyon oraný % 1.6, mortalite % 0.3 olarak gözlenmiþtir. Tanýsal amaçlý mediastinoskopilerde sýklýk sýrasýna göre Tüberkuloz ( % 54.3 ), sarkoidoz ( % 29.3 ), nonspesifik lenfadenit (%6), lenfoma (%2.6), timoma (%1.7), timus hiperplazisi (%1.7) ve diðerleri (%4.3) tanýlarý konmuþtur. Mediastinoskopi, güvenilir ve az invazif olmasýyla bir çok taný yönteminin yerini almýþtýr. Akciðer kanseri evrelemesinde altýn standarttýr.

Mediastinoscopy, although used primarily for staging of lung cancer, is also a less invasive method that can be used in diagnosis of intrathoracic diseases. Between March 1993 and December 2000 we have 610 total mediastinoscopy cases which 116 (19.01%) patients for diagnosis, 494 (80.9%) patients for staging. In addition to standard mediastinoscopy, exstended mediastinoscopy was done to 35 (7.08%) of staging cases and 7 (6.03%) of diagnosis cases. In evaluation of 494 nonsmall cell lung cancer patients which staging mediastinoscopy was done, 381 patients (77.1%) was found to be N0, 113 patients (22.3%) was found to be N2. In 32 of N2 positive 113 patients, N3 was positive. Number of cases which were found N0 in mediastinoscopy and were N2 after thoracotomy were 40 (10.4%). In our study we have found the sensivity of mediastinoscopy as 74 %, spesificity as 100 %, positive predictive value 100 %, negative predictive value as 88 %, and accuracy rate as 91 %: major complication rate was 1.6 %, and mortality was 0.3 %. In the diagnostic mediastinoscopies the diagnosis were tuberculosis (54.3%), sarcoidosis (29.3%), nonspesific lymphadenitis (6.03%), lymphoma (2.6%), thymoma (1.7%), thymus hyperplasia (1.7%), and the others (4.3%) in prevalence order. Medistinoscopy being a safe and less invasive method has taken the place of many diagnosing methods, and is the gold standart in staging of lung cancer.

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Çocuklarda pektus ekskavatum deformitesinin onarýmýyla ilgili deneyim ve uzun dönemli sonuçlarýmýzý deðerlendirdik. 981 - 2000 yýllarý arasýnda 39 hastaya (erkek:31, kýz:8) subperikondral deforme kartilaj rezeksiyonu ve sternuma anterior osteotomi yapýldý. Ortalama ameliyat yaþý 7.9 (2.2 - 15), pektus þiddet endeksi 4.1 (3.8 - 7.9)'di. Dört hasta hariç tümüne, Kirchner teliyle retrosternal destek uygulandý. Ýzlem süresi 5.2 yýl (7 ay-9 yýl) oldu. Hastalarýn % 79.5'inde (31/39) mükemmel, % 18'inde (7/39) iyi sonuç alýndý. Bir hastada kýsmi düzelme oldu (% 2.6). Sternal desteðin kullanýlmadýðý 4 hastadan 1'inde rekürren depresyon görüldü. Komplikasyon oraný % 13.1 oldu (yara enfeksiyonu 1, pnömotoraks 1, plevral efüzyon 1, atelektazi 1). Solunum yolu enfeksiyonlarý sýklýðý azaldý; egzersiz toleransý arttý ve göðüs aðrýsý yakýnmalarý düzeldi. Pektus deformitelerinde operasyon daha çok kozmetik nedenlerden yapýlmaktadýr; fakat ayný zamanda kardiyopulmoner fonksiyonlarýn da iyileþtiði söylenebilir. Optimal sonuçlar saðlayabilmek için teknik detaylara dikkat edilmelidir. Ameliyatla komplikasyon oraný düþük ve hastane süresi kýsadýr. Respiratuar semptomlarýn düzelmesi, eksersiz toleransýnda artma ve kozmetik düzelme % 97'den fazladýr.

We reviewed our operative experience and long-term results with repair of pectus excavatum deformities. From 1981 through 2000, 39 patients (male:31, female:8) underwent subperichondrial resection of deformed cartilages and anterior sternal osteotomy. Mean operative age was 7.9 (2.2 – 15) and pectus severity index 4.1 (3.8 - 7.9). All patients had retrosternal Kirchner bar support excluding 4. Mean follow-up was 5.2 years (7 mos–9 yrs). Results were excellent with 79.5 % (31/39), good 18 % (7/39) and partial 2.6 % (1/39). Recurrent depression was occurred in 1 patient who not performed sternal support. Complication rate was 13.1 % (wound infection 1, pneumothorax 1, pleural effusion 1, atelectasis 1). Frequency of respiratory infection decreased; exercise tolerance increased and chest pain removed. Operation in pectus deformities was generally performed due to cosmetical causes but it can also improve cardiopulmonary functions. Technical details must be noted for optimal results. Operation has less complication rate and short hospital time. Improvement in respiratory symptoms, increasing in exercise tolerance and good cosmetical results more than 97 %.

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Kronik obstrüktif akciðer hastalýðý (KOAH) ve infekte bronþiektazi tanýlarýyla kliniðimizde izlenen 73 yaþýndaki erkek olgu son beþ yýldýr her iki üst ekstremitesinde tekrarlayan þiþlik ve aðrýdan yakýnýyordu ve yakýnmalarý özellikle orta dereceli bir efordan sonra artýyordu. Sol elini kullanan ve çiftçilik yapan hasta þikayetlerinin son bir yýldýr sol el ve kolunda daha belirgin olduðunu ifade ediyordou. Fizik incelemede, sol ön kol ve el sýrtý belirgin ödemli ve hafif siyanotikti. Avuç içi ýsý ölçümleri solda saða göre 0.1-0.4°C fazlaydý. Adson hiperadduksiyon testi çift taraflý pozitifti. Torasik outlet sendromunun varlýðý elektronöromiyografiyle doðrulandý. Ancak radyolojik olarak buna neden olabilecek servikal kosta saptanmadý. Üst ekstremite venöz Doppler ultrasonografisinde, sol subklavyan vende trombüs görüldü. Tromboza neden olacilecek diðer nedenler dýþlandýktan sonra, olguya (Paget-Von Schroetter Sendromu-PVSS) tanýsý kondu. Oral antikoagülan ve sol kolun elevasyonu ile semptomlar geriledi. Daha önce subklavyan venin eforla geliþen trombozu diðer ismiyle PVSS, primer trombotik bir süreç olarak bilinmekteyken, son çalýþmalar bunun genellikle, tekrarlayan olasý mekanik basýnýn bir sonucu olabileceðini ileri sürmektedir. Üst ekstremitede tekrarlayan ve eforla artan ödem ve siyanoz varlýðýnda, PVSS'nun akýlda tutulmasý gerektiði kanýsýndayýz.

73 year-old male with COPD and infected bronchiectasis had suffered from swelling and pain in the upper limbs, aggreviating after moderate exertion, for five years. The symptoms of the left handed farmer was prominent in his left limb and had detoriated during the last year. On physical examination; the left arm, forearm and the dorsum of the hand was severely edematous and mildly cyanotic. The left palm temperature was 0.1-0.4°C higher than the right. Adson-hyperadduction test was positive, bilaterally. Thoracic outlet syndome was ascertained by electroneuromyography but cervical rib was never detected on the chest x-ray. On venous Doppler ultrasound, thrombus was fond in left subclavien vein. After teh exclusion of factors to cuase thrombosis, the diagnosis of (Paget-Von Schroetter Syndrome-PVSS) was established. The symptoms resolved after oral anticoagulant therapy and left limb elevation. Effort trombosis of subclavian vein, PVSS, has been considered a primary thrombotic process, but recent experience suggest that it may commonly result from repeated mechanical compressinon. We suggest to keep PVSS in mind when recurrent and/or effort related edema and cyanosis in the upper limb is found.

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Bronkoalveolar lavaj (BAL)'a baðlý pnömotoraks geliþimi çok nadirdir. Hafif astýmlý bir hastaya kliniðimizde BAL yapýldý. Ýþlem sonrasý pnömotoraks geliþti. Astýmlý hastalarda BAL uygulamasýnýn, komplikasyon olarak pnömotoraks geliþmesinde predispozan faktör olabileceðini bildirmeyi amaçladýk.

Pneumothorax is a very rare complication of bronchoalveolar lavage (BAL). We performed BAL in a patient with mild asthma in our clinic. After the procedure, he suffered from pneumothorax. The purpose of this report is to consider that patients with asthma are predisposed to developing pneumothorax as a complication of BAL.

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