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   Table of Contents - Current issue
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January-April 2021
Volume 23 | Issue 1
Page Nos. 1-75

Online since Friday, April 30, 2021

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REVIEW ARTICLES  

Role of ultrasound in the assessment of diaphragm function in patients with chronic obstructive pulmonary disease p. 1
Priya Ramachandran, Uma Devaraj, Louis Varghese, Kavitha Venkatanarayana, Uma Maheshwari Krishnaswamy, George D'Souza
DOI:10.4103/ejop.ejop_39_19  
Chronic obstructive pulmonary disease (COPD) characterized by irreversible airway obstruction, has numerous systemic complications including skeletal muscle dysfunction. Diaphragm, an important muscle of respiration, is also affected and it has far-reaching impact on morbidity. The study of diaphragm in individuals with COPD is challenging. Although the use of ultrasonography to study the function of diaphragm is in its nascent stage, it seems to be a promising tool for a comprehensive evaluation of diaphragm in COPD patients. This article reviews the available literature on the use of US in study of diaphragm on individuals with stable COPD.
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Current challenges and future scope of nanoparticles in chronic obstructive pulmonary disease p. 10
Sarika Pandey, Rajiv Garg, Surya Kant, Ajay Kumar Verma, Priyanka Gaur, Megha Agarwal
DOI:10.4103/ejop.ejop_57_19  
Chronic obstructive pulmonary disease (COPD), characterized by airway inflammation and progressive airflow limitation, is one of the leading causes of mortality worldwide. Bronchodilators, corticosteroids, or antibiotics are used for treatment of COPD, but the drugs are not delivered properly to the target cells or a tissue, which remains a challenge. Nanoparticles (NPs) have gained a tremendous interest in respiratory medicine due to their smaller size, higher surface to volume ratio, and advantages such as targeting effects, patient compliance, and improved pharmacotherapy. Sustained delivery of drugs mediated by NPs to the targeted site is needed to control cell chemotaxis, fibrosis, and chronic obstruction of lungs in COPD. Development of multifunctional biodegradable NPs that are nontoxic and can help in overcoming airway defense will be beneficial in future for COPD.
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ORIGINAL ARTICLES Top

Comparing respiratory symptoms and spirometry disorders among healthy people and workers of indoor swimming pools: A case–control study p. 14
Zohreh Yazdi, Mohammadali Zohal, Safiyeh Salimpour Abkenar
DOI:10.4103/ejop.ejop_3_19  
BACKGROUND: The water disinfection of swimming pools through chlorination method causes unwanted changes such as chlorine-containing byproducts within the air, which might affect the swimming pool workers' respiratory health. The present study is aimed to determine the frequency of respiratory symptoms and spirometry abnormalities among the workers of indoor swimming pools (instructors and lifeguards). MATERIALS AND METHODS: The present case–control study was conducted on forty individuals working in indoor swimming pools and forty others working at chlorine-exposure-free jobs as the control group. A questionnaire, including demographic information, smoking information, respiratory symptoms, and years of employment in the swimming pool, was completed for every participant. All the personnel, as well as the participants in the control group, underwent pulmonary examinations and spirometry tests. Then, the obtained data were analyzed using the SPSS 16 software as well as the statistical tests, including t-test, Chi-square test, correlation coefficient, and regression analysis. RESULTS: The mean age of the participants in the case and control groups was 32.3 and 32.5 years, respectively. Both the case and control groups consisted of 18 males (45%) and 22 females (55%). Among the respiratory symptoms, lacrimation, rhinorrhea, sneeze, throat irritation, and chest tightness were significantly higher in the case group than that of the control group (15%, 80%, 35%, 57.5% and 72.5% vs. 0%, 40%, 12.5%, 2.5% and 27.5%, respectively). The pulmonary examinations indicated a statistically significant difference between the two groups in terms of the prevalence of wheeze and rhonchi (P = 0.014 and 0.006, respectively). Moreover, showing a statistically significant difference, the forced vital capacity (FVC) and forced expiratory volume in 1 s/FVC indicators were lower in the case group than the control group (P = 0.04 and 0.016). CONCLUSION: Regarding the findings, there was a direct relationship between working in indoor swimming pools and the prevalence of respiratory symptoms and pulmonary dysfunction.
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Can hematological parameters guide the differentiation between sarcoidosis and tuberculous lymphadenitis? p. 19
Bugra Kerget, Yener Aydin, Sevilay Özmen, Dursun Erol Afşin, Elif Yılmazel Uçar, Leyla Sağlam
DOI:10.4103/ejop.ejop_6_20  
BACKGROUND: Tuberculosis (TB) and sarcoidosis, which are considered two different ends of the same disease spectrum, usually cannot be differentially diagnosed based on laboratory tests and radiological imaging. Clinical, histopathological, and bacteriological examinations as well as response to treatment can guide diagnosis. The aim of this study was to examine correlations between hematological parameters and disease in patients who were diagnosed with sarcoidosis, TB, or reactive lymphadenopathy (LAP) after mediastinoscopy. MATERIALS AND METHODS: The study included a total of 223 patients diagnosed with either reactive LAP (n = 65), sarcoidosis (n = 83), or TB (n = 75) after mediastinoscopy between September 2012 and May 2017. The patient groups were retrospectively evaluated in terms of demographic characteristics, complete blood count parameters, erythrocyte sedimentation rate, and radiological findings. RESULTS: Sedimentation rate and platelet count were significantly higher in TB patients compared with sarcoidosis (P = 0.001, P = 0.011) and reactive LAP patients (P = 0.001, P = 0.001). Lymphocyte count was significantly higher in patients with reactive LAP than in patients with TB and sarcoidosis (P = 0.001, P = 0.001). Platelet/lymphocyte ratio (PLR) was significantly higher in TB patients compared to those with sarcoidosis and reactive LAP (P = 0.001, P = 0.001) and in sarcoidosis patients compared to reactive LAP patients (P = 0.001). Neutrophil/lymphocyte ratio (NLR) values in the TB and sarcoidosis groups were significantly higher than that of the reactive LAP group (P = 0.001, P = 0.012). Stage 2 sarcoidosis patients were found to have significantly higher PLR, NLR, and platelet count compared to Stage 1 patients (P = 0.001, P = 0.01, P = 0.009). CONCLUSION: PLR and NLR can be used to discriminate patients with sarcoidosis and TB from patients with reactive LAP. In addition, PLR may also serve as a guiding parameter in the differentiation between tuberculous LAP and sarcoidosis.
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Efficacy and safety of autologous blood pleurodesis versus talc pleurodesis in symptomatic pleural effusions: A randomized trial p. 25
Muzaffer Metintas, Huseyin Yildirim, AK Guntulu, Gulden Sari, Selma Metintas
DOI:10.4103/ejop.ejop_23_20  
PURPOSE: This study aimed to compare the efficacy and safety of autologous blood pleurodesis with talc pleurodesis in patients with symptomatic pleural effusion. METHODS: This is a prospective, randomized, noninferiority trial. The smallest sample size was determined as 26 for each group by power analyses. For pleurodesis, 5 g of talc and 2 ml/kg blood were administered through the chest catheter. The success rate and complication were recorded in the 1st month after the procedures. The effect of the procedure on the successful pleurodesis was analyzed by univariate and then multivariate logistic regression analysis. RESULTS: A total of 60 patients were randomized. After randomization, 6 patients withdrew from the study. The overall success rate of pleurodesis was 72.0% in the autologous blood group and 69.0% in the talc group (P = 0.903). The most common complications were fever and pain, and both were higher in the talc group (P = 0.030 and P = 0.001, respectively). For successful pleurodesis, complete lung expansion and catheter duration (<7 days) were important factors in the talc group and in the autologous blood group, respectively (P = 0.001 and P = 0.034). The effect of the procedure on pleurodesis success was not significant (odds ratio [95% confidence interval): 1.51 [0.40–5.77]; P = 0.548) after adjustment for lung expansion and catheter duration. CONCLUSION: Autologous blood pleurodesis is a simple, inexpensive, effective procedure and no related to significant adverse events for patients with recurrent symptomatic pleural effusion. Especially, it can be preferred in patients with incomplete lung expansion. Further studies are required to confirm the results of this study.
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Does the benefit from pulmonary rehabilitation differ between phenotypes in chronic obstructive pulmonary disease? p. 32
Melih Buyuksirin, Gülru Polat, Hülya Şahin, Aysu Ayranci, Gülistan Karadeniz, Filiz Güldaval, Seher Susam, Fatma Üçsular, Ceyda Anar, Onur Süneçli
DOI:10.4103/ejop.ejop_26_20  
INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a disease caused by airway and/or parenchymal pathology. Therefore, some patients inevitably have chronic bronchitis and some patients have emphysema. The current thinking is that exercise affects these two major phenotypes differently. In this study, we investigated the benefits of pulmonary rehabilitation (PR) in chronic bronchitis- and emphysema-predominant COPD patients. METHODS: Retrospective data of chronic bronchitis- and emphysema-predominant COPD patients who completed an outpatient 8-week PR program between the years 2013 and 2017 in the PR unit of our hospital were examined. Demographic data (age, sex, body mass index, smoking history, long-term oxygen therapy, noninvasive ventilation, emergency admissions, and number of hospitalizations) were recorded. The patients were divided into two groups: chronic bronchitis predominant and emphysema predominant. Patients were assigned to the emphysema-predominant group based on radiology results. Patients were assigned to the chronic bronchitis-predominant group according to clinical description. The two groups were compared using the recorded data cited above. RESULTS: Of the 146 patients, 85 (58.2%) were assigned to the emphysema-predominant group and 61 (41.8%) were assigned to the chronic bronchitis-predominant group. There was no difference between the two groups in age and gender. Pulmonary function test (PFT) parameters (forced expiratory volume in 1 s and diffusing capacity of the lungs for carbon monoxide (DLCO)), arterial blood gas values (pO2, PCO2, and SpO2), 6 min of walking time, and quality of life scores were significantly improved after PR. However, there was no difference between the emphysema- and chronic bronchitis-predominant groups in terms of the improvements after PR. CONCLUSION: In this study, it was observed that the improvement due to PR seen in COPD patients was independent of phenotype. Therefore, all COPD patients should be encouraged to participate in PR programs regardless of their phenotypes.
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How was the management of patients scheduled for surgical biopsy through a multidisciplinary approach to the diagnosis of interstitial lung diseases? Was a pathological diagnosis alone enough? p. 41
Meltem Agca, Reyhan Yıldız, Baran Gundogus, Sumeyye A Bekir, Fatma Ozbaki, Aysun Kosif, Mine Demir Cankurtaran, Canan Akman, Aycim Sen, Armagan Hazar, Tulin Sevim, Dilek Ernam
DOI:10.4103/ejop.ejop_67_20  
OBJECTIVE: The present study examines the clinical and radiological findings and pathological diagnoses of patients undergoing surgical biopsy with an multidisciplinary team (MDT) decision and investigates whether final diagnoses change on the reevaluated of pathological diagnoses at MDT meetings. MATERIALS AND METHODS: A total of 416 patients were discussed at MDT meetings held at the University of Health Sciences Istanbul Sureyyapasa Chest Diseases and Thoracic, Surgery Training and Research Hospital January between January 2016 and May 2019, with surgical biopsy decisions made for 50 (12%) patients. RESULTS: Among the 50 patients, 26 (52%) were female, with a mean age of 53 ± 12 years. The most common locations of the surgical biopsy were the right lung (n = 27, 54%), lower lobe (n = 38, 76%) and single lobe (n = 35, 70%). A definitive pathological diagnosis was established in 41 (82%) patients following the biopsy. The most common diagnoses were usual interstitial pneumonia (UIP; n = 19, 38%), sarcoidosis (n = 11, 22%), unclassifiable fibrosis (n = 9, 18%), (non-specific interstitial pneumonia; n = 5, 10%), (hypersensitivity pneumonitis; n = 2, 4%) and others (n = 4, 8%), respectively. Diagnoses of 13 (26%) such patients were revised. The revision was most common in the unclassifiable fibrosis and UIP subgroups. The radiological appearance was classified based on the high-resolution computed tomography parameters for idiopathic pulmonary fibrosis (IPF). The final diagnosis was IPF in eight of 14 patients with “probable” diagnoses, all four patients with “indeterminate” diagnoses and three of the 28 patients with “alternative” diagnoses. CONCLUSION: Diagnosing interstitial lung diseases is difficult, and while surgical biopsy provides the most definitive diagnosis, it is not enough by itself. IPF may vary in radiology. Patients diagnosed with UIP and unclassifiable fibrosis after biopsy should be reevaluated, and the final diagnosis should be established through a multidisciplinary approach.
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Comparison of catheter-directed thrombolysis and anticoagulation in intermediate-risk pulmonary embolism: A retrospective analysis p. 50
Derya Ozden Omaygenc, Mehmet Onur Omaygenc
DOI:10.4103/ejop.ejop_73_20  
BACKGROUND AND OBJECTIVES: The selection of escalation of care strategies for the treatment of intermediate-risk pulmonary embolism (PE) is a matter of debate. Here, we aimed to assess the features of our population treated either with anticoagulation (AC) alone or catheter-directed thrombolysis (CDT). We also sought to identify a relationship between high residual systolic pulmonary artery pressure (sPAP) and demographic and clinical variables. PATIENTS AND METHODS: The retrospective data of 30 intermediate-high-risk PE patients were analyzed. CDT was used in 14 (46.7%) cases. Enoxaparin (b. i. d) injections were administered in the AC group. In the CDT group, patients received 5 mg bolus dose of alteplase followed by 1 mg/h infusion for 24 h. Estimated sPAP at presentation and discharge was recorded. A value equal to or greater than 40 mmHg in the latter was accepted as a significant rise. RESULTS: The patients in the CDT group had a lower HAS-BLED score (2 [0–3] vs. 1 [0–3], P = 0.03). Although initial sPAP values were comparable among treatment arms, sPAP at discharge was significantly lower in the CDT group (mmHg, 42 ± 11.2 vs. 33.6 ± 9.7, P = 0.04). The reduction in sPAP at discharge was also significantly higher in this group. The degree of reduction in sPAP was considerably correlated with baseline sPAP (r: 63.2, P < 0.001). Finally, the baseline sPAP measurement and HAS-BLED score of the patients with high residual sPAP were significantly higher (56.6 ± 13.1 vs. 67.3 ± 11.3, P = 0.02, and 1 [0–3] vs. 2 [0–3], P = 0.02, respectively). CONCLUSION: CDT was preferred over AC when lower bleeding risk was anticipated for intermediate-high-risk PE patients in our sample population. Eventually, CDT provided lower discharge sPAP levels and a greater reduction in sPAP. However, the factors associated with high sPAP at discharge were only high baseline sPAP measurement and HAS-BLED score.
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Efficacy and tolerability of antifibrotic agents in idiopathic pulmonary fibrosis: An experience from Turkey p. 59
Onur Turan, Bünyamin Sertoğullarından
DOI:10.4103/ejop.ejop_74_20  
INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is a progressive lung disease associated with poor prognosis. Antifibrotic drugs have come into use in the treatment of IPF, for which no effective therapeutic option existed until recently. This study makes an evaluation of IPF patients receiving pirfenidone or nintedanib as treatment. MATERIALS AND METHODS: This retrospective study included IPF patients who received antifibrotic therapy in our outpatient clinic between 2017 and 2020. The demographics, clinical symptoms, spirometric results, modified Medical Research Council (mMRC) and Leicester Cough Questionnaire (LCQ) scores, drug-related side effects, and treatment responses (at 6 months) were recorded. RESULTS: There were 52 patients (32:male-61.5% and 20:female-38.5%) with mean age of 70.65 ± 9.18. The most common presenting symptoms were dyspnea (86.5%) and cough (61.5%). The patients received pirfenidone (n = 31) and nintedanib (n = 21) therapies. The rate of side effects was 53.1%. At the 6-month control examination, 66% of the patients reported symptom relief. No significant difference was found in clinical symptoms, mMRC, respiratory parameters, or occurrence of side effects between the two treatment groups (P = 0.936, 0.393, 0.124, and 0.962, respectively). There was a stastistically significant improvement at LCQ score in patients treated with pirfenidone (P < 0.01). At the 6th month of the treatment process, there was a statistically significant improvement in the mMRC, LCQ scores, and forced vital capacity level (P < 0.01 all). CONCLUSION: The outcomes of antifibrotic therapy in IPF are particularly promising in terms of relieving clinical symptoms and the preservation of lung capacity. IPF patients receiving pirfenidone as a treatment seems to have a significant improvement in cough-related health quality.
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CASE REPORTS Top

Nitrofurantoin-related interstitial lung disease: Case report and literature review p. 64
Emine Arguder, Osama Abuzaina, Ayşegül Karalezli
DOI:10.4103/ejop.ejop_7_19  
Nitrofurantoin is an antimicrobial agent commonly used for urinary tract infections. This drug may cause pulmonary toxicities, the manifestations of which range from acute self-limiting reactions to chronic pathologies. Here, we report the case of a 72-year-old male who was admitted with progressive cough and dyspnea for 4 months. On physical examination, his respiratory rate was 26/min and oxygen saturation was 84% at rest while breathing room air. Chest examination revealed bilaterally fine crackles. His thorax computed tomography showed bilateral widespread ground-glass opacities and interlobular and intralobular septal thickening. His blood test revealed antinuclear antibody positivity. He had been using nitrofurantoin for a long time for urinary tract infection. He had a high score on Naranjo Adverse Drug Reaction Probability Scale. When he was a diagnosed, he had a respiratory failure due to lung damage. Patients using nitrofurantoin should be followed up closely for drug toxicity.
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The importance of pulmonary rehabilitation in lung transplantation p. 67
Manivel Arumugam, Ramanathan Palaniappan Ramanathan, Jnanesh Thacker, Srinivas Rajagopala, Pitchaimani Govindharaj
DOI:10.4103/ejop.ejop_29_20  
Lung transplantation is now the standard of care for nonreversible end-stage lung disease and leads to dramatic improvements in pulmonary function, quality of life, and survival. Pretransplant pulmonary rehabilitation (PR) can optimize potential recipients and widen or open a “transplant window” period. Given the potential for long wait times in our country, ongoing PR is crucial to ensure recipient fitness. Postoperative rehabilitation is an integral part of care of the recipient and may extend beyond hospital discharge. We present the case of a 42-year-old female who underwent bilateral lung transplantation for advanced interstitial lung disease and discuss the challenges and our approach to PR in this setting.
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Chemotherapy given lung cancer in intensive care unit p. 72
Aybuke Kekecoglu, Burcu İleri Fikri, Özkan Devran, Murat Haliloğlu, Ayşe Filiz Koşar
DOI:10.4103/ejop.ejop_7_20  
Lung cancer is the leading cause of cancer-related death among all types of cancers. In lung cancer patients, hospitalization rates in intensive care units (ICUs) are gradually increasing due to both illness- and treatment-related complications. A 61-year-old male patient who had undergone radiotherapy for small cell lung cancer (SCLC) was admitted to the ICU on the 3rd day of his treatment because of hypercapnic respiratory failure. High-flow oxygen therapy was started. The mass lesion showed rapid progression. Chemotherapy was performed for SCLC which is a chemosensitive tumor.
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