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   Table of Contents - Current issue
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September-December 2019
Volume 21 | Issue 3
Page Nos. 143-213

Online since Monday, December 30, 2019

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REVIEW ARTICLE  

Chronic obstructive pulmonary disease phenotypes: Are they really useful in clinical practice? p. 143
Evrim Eylem Akpinar, Derya Hoşgün
DOI:10.4103/ejop.ejop_55_18  
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. It is a complex and heterogeneous disease. In recent years, studies showed that forced expiratory volume in 1 s solely was not enough to describe heterogeneity of COPD patients, and subsequently, phenotypes of COPD were identified. The aim of phenotyping is the classification of patients into distinct subgroups according to the prognosis and response to therapy so that the selection of optimal therapy can be possible, and this clinical approach may improve prognosis. In the assessment and management of the disease, it is important to consider phenotype of a COPD patient. The aim of this article is to review predefined COPD phenotypes, their clinical and epidemiological features, and usefulness in clinical practice for accurate diagnosis and appropriate treatment of COPD patients.
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ORIGINAL ARTICLES Top

Efficient and safe method in the diagnosis of thoracic lesions: Ultrasound-guided needle aspiration biopsy p. 148
Coskun Dogan, Sevda Sener Cömert, Banu Salepçi, Nesrin Kiral, Elif Torun Parmaksiz, Benan Çağlayan
DOI:10.4103/ejop.ejop_75_19  
BACKGROUND: This study aimed to investigate the diagnostic value of fine-needle aspiration biopsy (FNAB) performed under the guidance of thoracic ultrasonography (USG) for the diagnosis of thoracic lesions such as peripheral lung lesions, pleural lesions, mediastinal lesions, and chest wall or supraclavicular metastases of lung lesions. MATERIALS AND METHODS: Cases with thoracic lesions that were found eligible for biopsy by thoracic USG and underwent FNAB between January 2008 and December 2016 were included in the study. Demographical characteristics and radiological findings of the cases, lesion size as detected by USG, sonographic patterns, number of FNABs per lesion, diagnosis based on FNAB, final diagnosis of inconclusive cases and the methods used to establish the final diagnosis, and developed complications were recorded. RESULTS: FNAB was performed for peripheral lung lesion in 188 (72.6%), mediastinal mass in 23 (8.9%), chest wall metastasis of lung tumor in 23 (8.9%), supraclavicular lymph node metastasis of lung tumor in 18 (6.9%), and pleural lesion in 7 (2.7%) cases. The corresponding diagnostic accuracy was 78.7%, 78.2%, 95.6%, 94.4% and 85.7%, respectively. A diagnosis could be made in 211 (81.4%) of 259 cases (195 [92.4%] malignant and 16 [7.6%] benign). The overall diagnostic success of the procedure was 81.4%, and the success rate to diagnose malignant and benign lesions was 81.9% and 76.1%, respectively. Pneumothorax which needs pleural tube in placement was seen in five patients, with peripheral lesion as the major complication. CONCLUSION: USG-guided FNAB performed for thoracic lesions is associated with a high rate of diagnostic success (81.4%) and a low rate of major complications (1.9%).
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Living- versus deceased-donor renal transplant recipients: A comparison on pulmonary complications p. 156
Ebru Sengul Parlak, Aysegul Karalezli, Mehmet Tokac, Ersin Gurkan Dumlu, Alpaslan Altinoglu, Fatma Tamara Cevik, Mehmet Kilic, Hatice Canan Hasanoglu
DOI:10.4103/ejop.ejop_56_18  
BACKGROUND: In renal transplant recipients, evaluation of pulmonary complications and investigation of reduction interventions are important due to the potentially fatal results of pulmonary complications after transplant surgery. However, data are lacking about pulmonary complications in renal transplant recipients with living- or deceased-renal donors. Therefore, we aimed to assess the pulmonary complications in living- versus deceased-donor renal transplant recipients. METHODS: We retrospectively searched the medical records of patients who underwent renal transplantation in our tertiary referral center between 2013 and 2018. Sociodemographic characteristics, pulmonary complications, and major comorbidities were compared according to the donor type (living or deceased). RESULTS: Fifty-two of 100 transplantations from living donors and 48 of 100 transplantations from deceased donors were formed the patient groups. There were no statistically significant differences in terms of sociodemographic and clinical characteristics between the groups except with regard to pneumonia complication. The pneumonia rates were 11/48 (22.9%) and 3/52 (5.8%), P = 0.020, for the deceased- and living-donor renal transplant recipients, respectively. Deceased-donor transplant recipients had a 4.8-fold risk of developing pneumonia (odds ratio, 4.8; 95% confidence interval, 1.2–18.6; P = 0.021). CONCLUSION: Deceased-donor renal transplant recipients are more vulnerable to pulmonary complications than are living-donor ones and should thus be monitored closely.
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Are thermogenic proteins and adipokine chemerin affected by monoclonal antibody therapy in asthma? p. 161
Tangul Bulut, Arzu Didem Yalcin, Betul Celik, Gizem Esra Genc, Ayse Yesim Gocmen, Saadet Gumuslu
DOI:10.4103/ejop.ejop_60_18  
BACKGROUND: Irisin is a thermogenic protein that sources outgoing energy by converting white adipose tissue to brown adipose tissue. Chemerin is originally identified as a chemoattractant protein that mainly mediating the chemotaxis of dendritic cells and natural killer cells (NKCs). The aim of this study is to assess the potential impact of immune modulation-related chemerin and irisin concentrations together with cell surface markers (CSM) in allergic asthmatic patients under omalizumab treatment. MATERIALS AND METHODS: The study participants were age- and sex-matched 30 healthy controls (Group I) and consecutive patients who had severe persistent asthma disease (Group II). Asthma patients took omalizumab treatment for 12 months within every 2 weeks. Flow cytometry analysis was used to evaluate CSM, enzyme-linked immunosorbent assay (ELISA) for interleukin-1 (IL-1) β expression. In addition, NK activity (NKA) and induced cytokine expression (by bioassay and ELISA, respectively) before and after omalizumab therapy were evaluated. RESULTS: Chemerin, irisin, and IL-1 β concentrations were significantly higher in severe persistent asthma patients compared to controls in serum (P = 0.01; P = 0.03; and P = 0.008, respectively). IL-1 β level decreased with treatment and it was statistically significant. Although levels decreased, no statistically significant difference was observed for Irisin, CD80, and CD56/16 levels. Chemerin level kept rising after treatment, and this was significant statistically. CONCLUSIONS: This is the first study to assess NKA and adipokines in asthma patients and their relationship with CSM. We observed that the level of these molecules is higher in asthma and is influenced by omalizumab treatment. Since no obvious change was observed for NKCs, omalizumab may be considered safe against cancer development.
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The efficacy of positron emission tomography-CT in simultaneously detected nodules in patients with lung cancer p. 167
Coskun Dogan, Nesrin Kıral, Elif Torun Parmaksız, Ömer Zengin, Benan Çağlayan, Ali Fidan, Sevda Şener Cömert, Banu Salepçi, Seda Beyhan Sağmen
DOI:10.4103/ejop.ejop_77_18  
BACKGROUND: The aim of this study is to evaluate the efficacy of positron emission tomography-computed tomography (PET-CT) in the diagnosis of ≤1 cm nodules detected during lung cancer diagnosis. MATERIALS AND METHODS: Patients with pulmonary parenchymal nodules ≤1 cm during the diagnosis of lung cancer between January 2014 and December 2016 were included in the study. The radiologic (size, location, shape, and contour properties) and radiometabolic (presence of fluoro 2-deoxyglucose [FDG] uptake in the nodule, presence and number of PET-CT mediastinal lymphadenopathy [LAP] uptake, mediastinal LAP maximum standard uptake value [SUVmax], presence and number of PET-CT extrapulmonary metastasis) features of the nodules were recorded. Nodules that were followed for at least 6 months and unchanged in size were considered benign, and those that increased or decreased in size or completely regressed were considered malignant. RESULTS: Of a total of 167 patients with lung cancer, 116 (69.4%) had no nodules and 51 (30.5%) had nodules. Of the 51 patients with nodules, 27 (53%) had benign and 24 (47%) had malignant nodules. Compared with patients with benign nodules, the FDG uptake rate, SUVmax values, mediastinal LAP uptake in PET-CT, SUVmax value of the mediastinal LAP with uptake, the number of mediastinal LAPs with uptake, and reported the presence and number of extrapulmonary distant organ metastases in PET-CT were statistically significantly higher in malignant nodules (P < 0.05). Moreover, FDG uptake of the nodule in PET-CT and the presence of mediastinal LAP uptake in PET-CT were independent predictors of malignancy of the nodules (P < 0.05). CONCLUSION: PET-CT parameters other than SUVmax can be used to interpret accompanying nodules smaller than 1 cm in patients with lung cancer.
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The effectiveness of lower limit of normal criteria and cutoff rate of forced expiratory volume in 1 s/forced expiratory volume in 6 s using in the diagnosis of airway obstruction in chronic obstructive pulmonary disease patients diagnosed with fixed ratio p. 175
Gokhan Erdogan, Esra Sonmez, Hisam Alahdab
DOI:10.4103/ejop.ejop_78_18  
AIMS: The definition of limited airflow as forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio for chronic obstructive pulmonary disease (COPD) is still controversial. The objective of this study was to compare the prevalence of COPD using fixed ratio and lower limit of normal (LLN) of FEV1/FVC for the presence of airflow limitation and evaluate the performance of FEV1/forced expiratory volume in 6 s (FEV6) in patients diagnosed with COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) fixed ratio. SUBJECTS AND METHODS: Patients who presented to the pulmonary disease clinic between May 2008 and December 2017 and who were diagnosed with COPD were evaluated retrospectively. The distribution of FEV1/FVC-LLN according to the GOLD fixed ratio was evaluated after the patients were divided based on age groups. A receiver operating characteristics curve was used to determine the best FEV1/FEV6 cutoff value which fit into the FEV1/FVC <LLN, and sensitivity and specificity were calculated. RESULTS: Of the patients, 165 (85.9%) were male and 27 were female, with a mean age of 64.40 ± 10.66 years (range, 40–85). Among the patients, 11.5% of 61 patients aged 40–60 years, 28.4% of 67 patients aged 61–70 years, and 26.6% of 64 patients aged over 70 years were out of the diagnosis of obstruction according to the fixed ratio of FEV1/FVC >LLN. The cutoff value of FEV1/FEV6 for airway obstruction according to FEV1/FVC <LLN was 0.735 with a sensitivity of 99.3%, a specificity of 95.3%, and area under the curve of 0.900 (95% confidence interval: 0.856–0.944, P < 0.001). CONCLUSIONS: In this study, older patients, particularly, were diagnosed less often with an FEV1/FVC <LLN value calculated according to the Global lung function initiative (GLI) norms, compared to the fixed ratio. In addition, ratio of FEV1/FEV6 of < 0.735 may be useful in the diagnosis of airway obstruction in the early period and may also be used in office-type spirometers, since it is not dependent on a time constant.
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Role of red cell distribution width in assessing response to treatment and prognosis in community-acquired pneumonia: A prospective study p. 182
Halit Cinarka, Aziz Gümüş, Songül Özyurt, Mevlüt Karataş, Derya Gıakoup, Medine Cumhur Cüre, Servet Kayhan, Deniz Dogan, Ünal Şahin
DOI:10.4103/ejop.ejop_80_18  
BACKGROUND AND AIM: Red blood cell distribution width (RDW) elevation occurs in various inflammatory/infectious conditions. RDW levels during monitoring have not been investigated prospectively in community-acquired pneumonia (CAP). In CAP, the relationship between antibiotherapy response and RDW levels is unclear. MATERIALS AND METHODS: This prospective cohort study included a total of 65 CAP patients. Total complete blood cell (including RDW) count, blood biochemistry analysis, and arterial blood gas tests were performed on admission. RDW was also performed on the 7th day. RESULTS: Total mean RDW level was 16.2% ± 1.9% in the study population. The level was 17.7% ± 2.1% in nonsurviving CAP patients and 15.9% ± 1.8% in surviving CAP patients (P = 0.01). Pretreatment RDW levels were 16.2% ± 1.9% as compared to 15.3% ± 2.2% on the 7th day (P = 0.002). An RDW cutoff >16.5% predicted 30-day mortality with 78% sensitivity and 70% specificity. The risk of 30-day mortality was 9-fold higher in patients with elevated RDW as assessed by multivariate logistic regression analysis for CAP. CONCLUSION: RDW can be used as an important parameter in assessing response to antibiotherapy. We also speculate that high RDW is a poor prognostic marker for CAP.
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Does neutrophil-to-lymphocyte ratio have a role among the other prognostic factors of nonsmall cell lung cancer? p. 187
Fatma Yildirim, Nurgül Sevimli, Murat Türk, Nilgün Yılmaz Demirci, Ahmet Selim Yurdakul, Can Öztürk
DOI:10.4103/ejop.ejop_2_19  
INTRODUCTION: Neutrophil-to-lymphocyte ratio (NLR), an index of systemic inflammation, has been associated with poor survival for many cancers. The aim of this study was to investigate the clinical significance of blood NLR in nonsmall cell lung cancer (NSCLC) as a prognostic factor. METHODS: We retrospectively reviewed medical records of patients with NSCLC and collected data from December 2009 to September 2013. NLRs were calculated at the time of diagnosis before any type of treatment. Data about NLR, age, sex, smoking, histopathology, Eastern Cooperative Oncology Group (ECOG) performance score, disease stage, serum albumin, and treatment modalities were investigated. These parameters were tested for its association with the 1-year, 2-year, and overall survival (OS); OS was calculated by the Kaplan–Meier analysis. RESULTS: A total of 121 patients with a median age of 61.9 (range 34–84), 14 (11.6%) female, and 107 (88.4%) males were included in the study. Majority of the patients were at local or advanced stage (Stage IIIA: 14.9%, Stage IIIB 14.9%, and Stage IV: 48.8%). Most common histological tumor type was squamous cell carcinoma (56.2%). Median neutrophil (N) count was 6.400 μl/ml, median lymphocyte (L) count was 1.570 μl/ml, while median NLR was 3.7. In univariate analysis, survival rates of patients did not have any differences according to gender, age, tumor histology, albumin level, and treatment modality (surgery and chemoradiotherapy). 1-year and 2-year survival rates of patients with ECOG 0 were higher than ECOG 1, 2, 3 patients (P = 0.034). Survival rates of Stage 1 patients (P < 0.001) and Stage 2 patients (P = 0.035) were longer, and survival rates of Stage 4 patients were lower than all other stages (P < 0.001). We divided the patients into 2 groups according to median NLR value of study group as NLR ≤3.7 and NLR >3.7. The percentage of patients who survived at the 1-year and 2-year were higher in the NLR <3.7 group (P = 0.043). The results showed that there was no significant difference regarding the patient's age, smoking history, tumor histology between 2 groups of high-level and low-level NLR. However, more male patients had higher NLR level (P = 0.036), and NSCLC patients with ECOG 2–3 (P = 0.002) and advanced disease stages (P< 0.001) were significantly associated with high-level NLR. Kaplan–Meier survival analysis revealed that there was a significant survival difference between NLR ≤3.7 and NLR >3.7 groups (14 vs. 9 months, P = 0.036). The multivariate Cox regression analysis revealed that the independent predictive factors for longer OS were low ECOG performance score (hazard ratio [HR] 0.786, 95% confidence interval [CI]: 0.799–0.931, P = 0.001), early disease stage (HR 1.517, 95% CI: 0.527–0.886, P < 0.001), and low NLR (HR 0.573, 95% CI: 0.440–0.962, P = 0.036). CONCLUSIONS: In our study, the increased NLR is an estimator of shorter survival in patients with NSCLC. NLR is an easy-to-measure, reproducible test that can be considered as a routine practice in patients with NSCLC.
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Long-term exercise parameter outcomes in obstructive sleep apnea patients with and without positive airway pressure therapy p. 193
Elif Yılmazel Ucar, Ömer Araz, Bugra Kerget, Metin Akgun, Leyla Saglam
DOI:10.4103/ejop.ejop_4_19  
BACKGROUND: Short-term studies have shown that positive airway pressure (PAP) therapy increases exercise capacity in obstructive sleep apnea syndrome (OSAS). In this study, we investigated the effect of PAP therapy on exercise parameters in OSAS patients who were followed for 2 years. MATERIALS AND METHODS: This prospective cohort study included patients recently diagnosed with moderate-to-severe OSAS. The patients underwent cardiopulmonary exercise testing and pulmonary function testing (PFT) at the start of the study and at follow-up visits. Outcomes of patients who adhered to regular treatment were compared with those who refused treatment. RESULTS: Thirty-one patients who attended follow-up were included in the analysis and evaluated as a treated group (n = 16) and untreated group (n = 15). Although patients in the treated group had more comorbidities, the proportion of smokers was higher in the untreated group (P = 0.36 and P = 0.36, respectively). Of the PFT parameters, there were no changes in forced vital capacity and forced expiratory volume in 1 s in both the groups (P = 0.85, P = 0.59 and P = 0.92, P = 0.90, respectively). In the treatment group, there were decreases in resting heart rate (HR) and oxygen saturation compared to baseline levels (P = 0.01 and P = 0.02). A statistically significant decline in breathing reserve was observed in the untreated group (P = 0.03). CONCLUSION: Our study suggests that PAP treatment does not make any difference in exercise parameters and PFT in long term. However, it supports the fact that PAP treatment may have a positive effect on some cardiac parameters, such as HR rest.
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Psoriasis and chronic obstructive pulmonary disease association p. 199
Fareed Shawky Basiony, Mohamed Osama Nour
DOI:10.4103/ejop.ejop_41_19  
BACKGROUND: The inflammation that occurs with psoriasis can affect both lungs and raise the risk for chronic obstructive airway disease, and hence, pulmonary function should be studied in patients with psoriasis. AIM OF THE WORK: The study aimed to detect the relationship between psoriasis and chronic obstructive pulmonary disease (COPD). SUBJECTS AND METHODS: A case–control study was conducted at El-Hussein University Hospital, Al-Azhar University. Sixty patients with psoriasis and sixty control patients were involved in this study. Spirometry was performed in all the study patients. RESULTS: The present study included 60 psoriasis patients and age- and gender-matched 60 controls fulfilling inclusion criteria. No statistically significant differences were found between two groups as regards age, gender, and residence. However, patients with psoriasis were significantly more frequently smokers, overweight, obese, and diabetic. In addition, obstructive pulmonary functions were significantly higher among psoriasis patients. Overall, COPD was diagnosed in 10.0% of psoriasis patients compared with 5.0% of controls but with no statistically significant difference. The mean forced expiratory volume in 1 s/forced vital capacity ratio and forced expiratory flow at 25%–75% were significantly lower in the psoriasis patients than in the controls (80.4 ± 5.6 vs. 93.1 ± 5.4, P < 0.001 and 85.6 ± 9.1 vs. 95.5 ± 5.8, P < 0.001, respectively). Overweight, obese, and diabetic psoriasis patients were at increased risk of COPD than controls (odds ratio = 2.0, 2.5, and 1.7; 95% confidence interval, 0.89–4.45, 0.86–7.31, and 0.92–3.32), respectively. CONCLUSIONS: Psoriasis patients were likely to develop COPD. RECOMMENDATION: COPD should be screened by spirometry among psoriasis patients and advise them to stop smoking and control weight and diabetes to reduce COPD development.
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CASE REPORTS Top

Pulmonary eosinophilia associated with recent waterpipe smoking p. 204
Muhammet Nesim Reşat Noristani, Pınar Yıldız Gülhan, Cemil Işık Sönmez, Mehmet Gamsizka
DOI:10.4103/ejop.ejop_11_19  
Acute eosinophilic pneumonia (AEP) is one of the causes of acute respiratory failure. Classical clinical picture includes acute febrile illness, bilateral pulmonary opacities, pulmonary eosinophilia, hypoxia, and pleuritic chest pain. We observed AEP with atypical presentation after recent waterpipe (hookah) smoking in our patient. We reported the case of a male with laboratory AEP findings without the typical clinical presentation which resolved after abstinence from waterpipe smoking.
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Double whammy: A rare disorder complicating a common infection – A case report and review of literature p. 207
Uma Devaraj, Priya Ramachandran, K Uma Maheswari
DOI:10.4103/ejop.ejop_50_19  
Gorham-stout disease (gsd), is a rare disorder of unknown etiology. although a non-malignant, non-infectious condition, gsd results in massive destruction of bones by osteolysis secondary to proliferation of blood vessels. we present a young man afflicted with this condition with coexisting tuberculous pleural effusion and the successful outcome with treatment.
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LETTER TO EDITOR Top

Tele-auscultation of respiratory sounds with a low-cost digital stethoscope p. 212
Himel Mondal, Shaikat Mondal
DOI:10.4103/ejop.ejop_49_19  
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