Ahmet Ilvan

Assessment of Long-term Omalizumab Treatment in Patients with Severe Allergic Asthma Long-term Omalizumab Treatment in Severe Asthma

Objective. Several clinical studies have demonstrated the effectiveness of omalizumab in patients with severe allergic asthma but the treatment period has always been relatively short (4–12 months). In the literature, there are a few data about the long-term omalizumab therapy. We aimed to assess the long-term clinical and functional effectiveness of omalizumab treatment in severe allergic asthmatic patients, Methods. Medical records describing the patients’ status before the start of treatment, and also having been registered at the end of 4th, 12th, and 36th months from the commencement of treatment, and at the last visit where the patient was evaluated were used for omalizumab effectiveness assessments. Twenty-six patients (female/male: 21/5) with severe allergic asthma, uncontrolled despite GINA 2006 Step 4 therapy, were included in the study. Effectiveness outcomes included spirometry measurements, level of asthma control measured by asthma control test (ACT), systemic glucocorticosteroid (sGCS) use, emergency room (ER) visits, and hospitalizations for severe exacerbations. In addition, the quality of life was assessed using the quality of life questionnaire AQLQ(S) before, 4, and 36 months after treatment, Results. The mean age was 47.6 ± 13.9 and duration of allergic asthma was 22.7 ± 10.1 years. Serum total IgE levels were 322.0 ± 178.1 IU/mL. Mean duration of omalizumab treatment was 40.81 ± 8.2 months. FEV1 improved significantly at all control points versus baseline (p < .05). The level of asthma control as evaluated by ACT improved significantly after treatment (p < .05). We determined significantly reduced numbers of exacerbation, emergency visits, hospitalizations, sGCS, and SABA use by the end of 36 months (p < .05). The proportion of patients with improvements larger than 1.5 points in AQLQ(S) total score was 80.7% at the 4th month and 96.1% at the 36th month of treatment, Conclusions. This study showed that long-term therapy with omalizumab for up to 3 years was well tolerated with significant improvement both in symptoms and lung functions. Accordingly, long-term omalizumab treatment may be recommended for responders.

Effect of Corticosteroids on Hemostasis and Pulmonary Arterial Pressure during Chronic Obstructive Pulmonary Disease Exacerbation

Background: Hemodynamic and hemostatic abnormalities are reportedly frequent in chronic obstructive pulmonary disease (COPD). Objectives: We investigated the changes in systolic pulmonary artery pressure (PAPs) and hemostatic status and the effects of systemic steroid treatment (SST) during COPD exacerbation. Methods: Consecutive 26 male and 4 female patients as well as 10 controls were enrolled. The nonsteroid treatment (NST) group received standard treatment without steroids, and the other group received additional SST. Initial values of blood gases, spirometry and PAPs, P-selectin, D-dimer and fibrinogen levels, activities of thrombocyte aggregation, antithrombin III (AT III), protein C (PC), protein S, activated PC resistance (APCR), prothrombin time and partial thromboplastin time were obtained and compared with values at day 10. Results: Improvement in spirometry and blood gases was more prominent with SST. At presentation, patients had higher PAPs, P-selectin, D-dimer and fibrinogen but lower AT III levels than controls. PAPs and fibrinogen levels significantly decreased in the SST group while P-selectin levels further increased in the NST group. The D-dimer level significantly decreased in both groups. Means of AT III, PC and protein S increased in the SST and decreased in the NST group, but only the decrease in PC in the NST group was meaningful. Compared with the controls, AT III levels in the NST group and activated PC resistance in the SST group were significantly decreased. Thrombocyte aggregation tests suggested an incline after 10 days in both groups. Conclusions: We suggest that in patients with COPD exacerbation, addition of systemic corticosteroids to treatment results in better outcome in normalization of PAPs, hemostasis, pulmonary functions and blood gases.

The effect of pleural fluid content on the development of pleural thickness

SETTING Residual pleural thickness (RPT) is a common complication of tuberculous pleurisy (TP), and the degree of RPT cannot be predicted in advance. OBJECTIVES To determine whether pleural fluid content has an effect on the development of RPT. DESIGN Forty-seven patients with TP were enrolled in the study. A set of biochemical tests: lactate dehydrogenase, glucose, total proteins, adenosine deaminase, tumour necrosis factor alpha (TNF-alpha), alpha-1 acid glycoprotein (AAG), alpha-2 macroglobulin, C-reactive protein (CRP), complement 3 and complement 4 were studied in the pleural fluid samples. After 6 months of anti-tuberculosis treatment, patients were re-evaluated for RPT. RPT was defined in a posteroanterior chest radiograph as a pleural space of >2 mm or >10 mm measured in the lower lateral chest at the level of an imaginary horizontal line intersecting the diaphragmatic dome. RESULTS Seventeen patients (36.17%) had an RPT of <2 mm, 18 (38.29%) had an RPT of 2-10 mm, and 12 (25.53%) had an RPT of >10 mm. TNF-alpha levels were lower in patients with an RPT of <2 mm than in patients with an RPT of 2-10 mm or >10 mm (P < 0.05 and P < 0.01, respectively). The level of TNF-alpha was higher in patients with an RPT of >10 mm compared to the 2-10 mm group (P < 0.05). Meanwhile, pleural fluid glucose, AAG and CRP concentrations were significantly higher in patients with an RPT of >10 mm than in patients with <2 mm RPT (P < 0.05, P < 0.01, and P < 0.05, respectively). CONCLUSION In TP, the development and degree of RPT are significantly correlated to the glucose, CRP, AAG, and TNF-alpha levels in the pleural fluid.

Primary Antituberculosis Drug Resistance at Turkish Military Chest Diseases Hospital in Istanbul

Objective: The aim of this study was to investigate the prevalence of primary drug resistance to tuberculosis. Methods: We evaluated the clinical data, radiological features and sputum samples from 365 newly diagnosed patients with a positive culture of pulmonary tuberculosis at the Turkish Military Chest Diseases Hospital, Istanbul, Turkey. No patients had taken antituberculosis drugs previously. The Bactec method was used to perform drug susceptibility testing for isoniazid, rifampicin, ethambutol, and streptomycin. Results: Primary resistance to one or more drugs was detected in 87 (23.8%) patients; resistance to isoniazid was most common (54 patients) followed by resistance to ethambutol (n = 39), rifampicin (n = 11), and streptomycin (n = 9). One-drug resistance was detected in 69 patients; two-drug resistance in 11, three-drug resistance in 6, and four-drug resistance in 1. Multidrug resistance (resistance to at least isoniazid and rifampicin) was detected in 10 patients. In logistic-regression analysis, primary drug resistance was associated with radiological advanced tuberculosis (p < 0.001). Conclusion: Primary resistance to one or more drugs used in treating tuberculosis is relatively high. It is necessary to regularly screen for and treat drug resistance among those who live in close quarters, such as army barracks, school dormitories and prisons. Regular surveillance of drug sensitivity patterns should be maintained to determine appropriate alternate drug regimens and detect the spread of resistant stains in the population.

A case of Behcet's disease with pulmonary artery aneurysm and thrombosis

A 22 year old patient with dyspnea, cough, chest pain, fatigue, mild fever and swelling of the lower extremities was hospitalized. Physical examination revealed bilateral decrease in respiratory sounds and end-inspiratory fine rales at the left posterobasal area. Circumferences of both legs were increased. During hospitalization period, oral aphthous and scrotal ulceration were appeared. Bilateral multiple peripheral and central pulmonary artery aneurysms at middle zones were found with dynamic computerized tomography of thorax and magnetic resonance angiography of the lungs. Patient was diagnosed as Behcets disease with lung involvement. Magnetic resonance angiography performed at the sixth month of the treatment revealed a significant regression in aneurysmatic changes, whereas a right ventricular thrombosis had been developed.

Small cell lung cancer with metastasis to the thyroid in a patient with toxic multinodular goiter.

Thyroid metastasis of lung cancer is rarely observed in clinical practice. The primary cancers which metastasize to the thyroid gland are mostly renal cell carcinoma, lung cancer, and breast cancer. Transient destructive thyrotoxicosis is caused by massive metastasis of extrathyroid tumors. We herein present a case report of a patient with small cell carcinoma of lung with metastasis to the thyroid and thyrotoxicosis due to toxic multinodular goiter. A 66-year-old man complained of swelling around the right side of the neck, dyspnea, progressive weight loss, and palpitation starting since 3 months before his admission. The patient was diagnosed with small cell carcinoma of lung with metastasis to the thyroid and thyrotoxicosis due to toxic multinodular goiter. The case report presented here illustrates the challenge of making a definitive and adequate diagnosis, particularly if the patient presents with 2 potential causes of thyrotoxicosis. Thyroid scintigraphy is an important tool for differential diagnosis of thyrotoxicosis.

Pyo-Pneumothorax in Patients with Active Pulmonary Tuberculosis: An Analysis of 17 Cases without Intrapleural Fibrinolytic Treatment

Objective: To review the medical records of patients with active pulmonary tuberculosis (TB) and pyo-pneumothorax (PPT). Subjects and Methods: Medical records of 17 patients (14 male, 3 female, mean age 23.8 years, range 20–52) with PPT and active pulmonary tuberculosis at Gulhane Military Medical Academia Haydarpasa Training Hospital, Istanbul, Turkey, were reviewed from January 1998 to December 2002. The patients were treated with chest tube drainage and chemotherapy. Intrapleural fibrinolytic agents or irrigation was not performed. Results: Pleural fluid samples were available in 14 patients and the mean levels of LDH, protein and glucose in the pleural fluid were 1,767 ± 944 U/l, 5.2 ± 1.4 g/dl and 31.7 ± 22.6 mg/dl, respectively. Mycobacterium tuberculosis was detected in the pleural effusion of 3 patients. The duration of chest tube drainage was longer in cases who underwent open drainage (p = 0.014). At the end of the treatment period 10 patients developed pleural thickening, 4 of them underwent decortication and pneumonectomy was also done in 1 patient. The development of pleural thickening was related to the level of pleural fluid glucose (p = 0.04). Conclusion: This study shows that while taking care of patients with pulmonary TB the physician must be aware of the complication of PPT and that adequate chemotherapy and drainage must be duly performed.

Deaths in patients with pulmonary tuberculosis: an analysis of a chest diseases hospital in Istanbul, Turkey.

Objective: To evaluate the medical records of patients with pulmonary tuberculosis in order to determine the inhospital mortality rate. Materials and Methods: Medical records of 22,651 patients with pulmonary tuberculosis admitted to Gulhane Military Medical Academia, Camlica Chest Diseases Hospital, Istanbul, Turkey from 1977 to 1999 were examined. Results: Of the 22,651 patients, 133 (0.58%) died: 117 male and 16 female, mean age 41.5 ± 20.7 years. The mean length of hospital stay was 15.8 ± 25.9 days and it increased yearly (p = 0.004). There was no significant difference in hospital mortality rate of tuberculosis within years. Forty-nine patients had chronic and/or far advanced tuberculosis, 36 of them had concomitant diseases. Thirteen patients had miliary and/or tuberculous meningitis, 3 multi drug-resistant tuberculosis, another 3 had pneumothorax, and 2 empyema. These patients had significantly lower prognostic nutritional index than those patients who recovered from pulmonary tuberculosis (p = 0.025). Conclusion: Inhospital mortality rate of tuberculosis did not change in the last 23 years. We suggest that pulmonary tuberculosis will continue to be a significant cause of death and therefore important health care problem for Turkey in the 21st century.