Nazan Sen

Tuberculosis in Patients With End-Stage Renal Disease Undergoing Dialysis in an Endemic Region of Turkey

The incidence of tuberculosis (TB) is high in end-stage renal disease (ESRD) patients undergoing dialysis. Diagnosis is difficult and delayed in this patient group owing to extrapulmonary involvement and nonspecific symptoms. Adverse effects of antituberculosis treatment are seen more frequently in these patients. We retrospectively evaluated the frequency and clinical progression of TB in 18 of 343 dialysis patients diagnosed with TB over a 5-year period at a university hospital in Adana, Turkey. Mean time between initiation of dialysis to diagnosis of TB was 19.5 +/- 26.1 months. Extrapulmonary TB was more frequent (77.8%) than pulmonary TB (22.2%). Diagnosis of TB was made based on clinical data in 1 patient, and microbiologically or pathologically in others. Antituberculosis treatment with 3 or 4 drugs was administered to patients for 6 to 12 months; second-line treatment was initiated in 1 patient infected with multidrug-resistant bacilli. One patient died owing to a cause other than TB; another was lost to follow-up. Adverse effects were hepatotoxicity in 3, optic neuritis in 1, and neuropsychiatric in 3 patients. A clinical response to therapy was achieved in all of the 16 patients who completed treatment. In conclusion, the incidence of TB and the frequency of extrapulmonary involvement are high in dialysis patients. Physicians must be alert to unusual presentations and localizations of the disease; TB must be strongly suspected in endemic regions. Owing to the greater frequency of adverse effects of treatment in these patients, they must be carefully observed during treatment.

Chest radiography and CT findings in patients with the 2009 pandemic (H1N1) influenza.

PURPOSE To present chest radiography and thoracic computed tomography (CT) findings for patients with pandemic influenza A (H1N1) from November-December 2009 and to explore any differences compared to previously reported imaging findings. MATERIALS AND METHODS Fifty-two hospitalized patients with pandemic influenza (H1N1) were included in the study. All of the patients underwent chest radiography, and 28 patients were also evaluated by thoracic CT. Group 1 comprised 24 (46%) patients with no identified risk factors for H1N1 influenza infection. Group 2 comprised the remaining 28 (54%) patients with identified risk factors. The distribution of lung involvement, consolidation, ground-glass opacity (GGO), lymph nodes, and pleural effusion were evaluated. RESULTS Abnormal findings were observed in 85% of the patients. Bilateral lung involvement was present in 80% of the patients. The most common finding was a mixture of GGO and air-space consolidation. Lower zone predominance occurred in 89% of group 1 and 85% of group 2 patients. The involvement was observed most frequently in the peripheral and central perihilar areas of the lung in 80% of the patients. The extent of disease was greater in group 2 patients with the involvement of three or more lung zones in 62% of the patients. CONCLUSION The most common imaging finding for lung involvement was a mixture of air-space consolidation and GGO with a patchy pattern and lower/middle zone predominance. Pulmonary involvement of the disease was more extensive than that described in previous reports.

Propylthiouracil-Associated Eosinophilic Pleural Effusion: A Case Report

We describe an unusual case of a patient with eosinophilic pleural effusion (EPE) associated with long-term propylthiouracil (PTU) administration. A 43-year-old woman was admitted to our hospital after complaining of chest pain. She had had Graves’ disease, which had been treated with PTU for 11 years. Right-sided pleural effusion was detected and the result of thoracentesis confirmed an EPE. The patient’s detailed medical evaluation failed to reveal any other cause of EPE. PTU was terminated since it was thought to be the cause. Despite withdrawal of the medication, however, the pleural effusion persisted for 6 weeks, and steroid therapy was planned for 15 days in decreasing dosages. During the control visit 10 days after the initiation of steroid therapy, no pleural effusion was observed, and the steroid was discontinued. Rechallenge with PTU produced recurrent pleural effusion. Therapy with PTU was again terminated, and treatment with methimazole and a brief course of low-dose corticosteroids were begun. Chest radiography revealed disappearance of the effusion within 10 days and it did not recur during a 1-year follow-up. To our knowledge, there is only 1 other case in the English-language literature describing EPE caused by PTU. Our report is of particular importance because it describes the development of that disorder in the 11th year of PTU treatment. It also shows that steroid therapy can be effective in treating drug-induced EPE.

QT dispersion in patients with pulmonary embolism

ZusammenfassungHINTERGRUND: Verschiedene EKG Veränderungen sind mit der akuten Pulmonal-Embolie in Zusammenhang gebracht worden. Bezüglich möglicher Veränderungen des QT-Intervalls liegen allerdings keine Daten vor. Das Ziel unserer Studie war es, zu prüfen, ob es einen Zusammenhang zwischen Veränderungen des QT Intervalls und dem Schweregrad der Pulmonalembolie gibt. METHODEN: 129 Patienten mit Pulmonalembolie (mittleres Alter 58 ± 16.5 Jahre) mit einem EKG innerhalb der ersten 24 Stunden nach Spitals-Aufnahme wurden in die Studie inkludiert. Die Patienten wurden in Gruppen mit niedrigem, mit mittlerem und mit hohem Risiko eingeteilt. Retrospektiv wurden folgende EKG Parameter bei alle Gruppen gemessen: korrigierte maximale und minimale QT-Zeit (QTcmax und QTcmin) und korrigierte QT-Intervall Dispersion (QTcd, definiert als die Differenz zwischen QTcmax und QTcmin). Ausserdem wurde ein EKG score (bestehend aus Sinustachycardie, komplettem und inkomplettem Rechtsschenkelblock, T Inversion und S1Q3 Typ) erstellt. ERGEBNISSE: Der EKG score stieg vom niedrigem zu hohem Risiko der Pulmonalembolie an [3 (Interquartile Range, IQR: 2), 5 (IQR: 6) und 10 (IQR: 7) p < 0,0001]. Die QT Intervall Analyse zeigte, dass die QTcd in der Hoch Risiko Gruppe höher als in den Gruppen mit niedrigem und mittleren Risiko war (59,5 ± 23,4, 69,2 ± 21, 95,9 ± 33,2, p < 0,001 beziehungsweise p = 0,01). Patienten, die nach Diagnosestellung starben hatten signifikant höhere QTcd Werte bei der Aufnahme als die überlebenden Patienten (89,1 ± 45,5 to 65 ± 22,9, p = 0,001). Die Sensitivität eines QTcd von mehr als 71,5 ms in Bezug auf die Vorhersagefähigkeit bezüglich Mortalität war bei 71%. Die Spezifität bei 73% (p = 0,001). Wir beobachteten einen hoch signifikant Zusammenhang zwischen QTcd und den EKG score Werten (r = 0,69, p < 0,001). Der Pulmonalarterien Druck war auch – allerdings deutlich schwächer - mit den QTcd Werten korreliert (r = 0,27, p = 0,05). SCHLUSSFOLGERUNGEN: Die QTcd steigt bei Hoch Risiko Pulmonalembolie Patienten im Vergleich zu Patienten mit geringerem Risiko signifikant an. Außerdem ist die QTcd signifikant mit dem EKG score und dem Pulmonalarteriendruck korreliert.SummaryBACKGROUND: Various ECG patterns have been associated with acute pulmonary embolism. However, there is no data regarding the association between QT interval measurements and pulmonary embolism. We aimed to investigate the association between QT dispersion and the severity of pulmonary embolism (PE). METHODS: One hundred twenty-nine pulmonary embolism patients (mean age 58 ± 16.5 years) with ECGs obtained within the first 24 hours of hospital admission were included in the study. Patients were classified into low, intermediate and high-risk groups. We retrospectively measured ECG scores; maximum and minimum corrected QT intervals (QTcmax and QTcmin) and corrected QT interval dispersion (QTcd) in each risk group of patients. RESULTS: There was an increasing ECG score through from low to high-risk PE [3 (Interquartile Range, IQR: 2), 5 (IQR: 6) and 10 (IQR: 7) p < 0.0001]. QT interval analysis showed that QTcd was higher in high-risk group than in low and intermediate-risk groups (59.5 ± 23.4, 69.2 ± 21, 95.9 ± 33.2, p <0.001 and p = 0.01, respectively). Patients who died after diagnosis had significantly higher QTcd values at baseline compared with the QTcd values of surviving patients (89.1 ± 45.5 to 65 ± 22.9, p = 0.001). The sensitivity of QTcd > 71.5 ms for prediction of mortality was 71% with a specificity of 73% (p = 0.001). We observed a strong correlation between QTcd and ECG score values (r = 0.69, p< 0.001). There was also a correlation between QTcd values and pulmonary artery pressure (PAP) (r = 0.27, p = 0.05). CONCLUSION: QTcd is significantly increased in high-risk PE patients compared to intermediate and low-risk patients. In addition, QTcd is significantly correlated with ECG score and PAP.

The approach to community-acquired pneumonia: A survey study

INTRODUCTION AND AIM: Community-acquired pneumonia (CAP), which is often seen in daily practice, is a lower respiratory tract and pulmonary parenchyma infection which develops in society and daily life with community-acquired pathogens in individuals with no known immune failure. Delay in the treatment of pneumonia is known to increase morbidity and mortality. Various scoring systems are currently used in the identification of treatment groups in pneumonia. With the aim of evaluating the approach to CAP cases, the infection. MATERIALS AND METHODS: Working Group of the Turkish Respiratory Research Association (TUSAD) prepared a 22-item questionnaire. RESULTS: The survey was published on the TUSAD official website between July 2013 and June 2016. A total of 78 individuals responded to the questionnaire on the website. CONCLUSION: The responses to the questionnaire could indicate the way forward for new guidelines for physicians in respect of the approach to CAP.

What should be the appropriate minimal duration for patient examination and evaluation in pulmonary outpatient clinics

Introduction: Patient examinations performed in a limited time period may lead to impairment in patient and physician relationship, defective and erroneous diagnosis, inappropriate prescriptions, less common use of preventive medicine practices, poor patient satisfaction, and increased violent acts against health-care staff. Objective: This study aimed to determine the appropriate minimal duration of patient examination in the pulmonary practice. Methods: A total of 49 researchers from ten different study groups of the Turkish Thoracic Society participated in the study. The researchers were asked to examine patients in an almost ideal manner, without time constraint under available conditions. Results: A total of 1680 patient examinations were reviewed. The mean duration of patient examination in ideal conditions was determined to be 20.4 ± 9.6 min. Among all steps of patient examination, the longest time was spent for “taking medical history.” The total time spent for patient examination was statistically significantly longer in the university hospitals than in the governmental hospitals and training and research hospitals (P < 0.001). Among different patient categories, the patients with a chronic disorder presenting for the first time and were referred from primary or secondary to tertiary care for further evaluation have required the longest time for patient examination. Conclusion: According to our study, the appropriate minimal duration for patient examination is 20 min. It has been observed that in university hospitals and in patients with chronic pulmonary diseases, this duration has been increased to above 25 min. The durations in clinical practice should be planned accordingly.