Sermin Borekci

Factors Affecting the Tuberculosis Risk in Patients Receiving Anti-Tumor Necrosis Factor-α Treatment

Background: Tumor necrosis factor (TNF)-α inhibitors are known to increase the risk of tuberculosis (TB). Objectives: To examine the factors associated with an increased risk of TB in patients receiving anti-TNF-α treatment (aTNF-α-T). Method: Of 3,094 patients who received aTNF-α-T between 2003 and 2013, a total of 1,964 subjects with a follow-up time longer than 6 months were identified and included in this retrospective analysis. Potential risk factors for the development of TB in patients receiving aTNF-α-T were evaluated. Results: Of the 1,964 patients, 1,009 (51%) were male and 955 (49%) were female, with a mean age of 39.7 ± 13.9 years. The primary conditions requiring aTNF-α-T included ankylosing spondylitis (n = 875), rheumatoid arthritis (n = 711), Behçets disease (n = 83), and others (n = 295). Sixteen patients [8 (50%) males and 8 (50%) females; 5 (31.2%) with pulmonary TB and 11 (68.8%) with extrapulmonary TB] developed TB, with a corresponding TB incidence of 466/100,000. No significant associations were found between age, gender, smoking history, pack-years of smoking, isoniazid (INH) chemoprophylaxis, type of anti-TNF-α agent, use of other immunosuppressive drugs, and the risk of TB (p > 0.05). Multivariate logistic regression analysis showed a significantly higher risk of TB in patients diagnosed with Behçets disease, and a significantly lower risk of TB in patients with a tuberculin skin test wheal ≥10 mm in diameter (p < 0.05). Conclusion: aTNF-α-T is associated with an increased risk of pulmonary or extrapulmonary TB, even when follow-up protocols and INH chemoprophylaxis are implemented, and TB often develops in the later stages of treatment. The risk of TB was higher in patients with Behçets disease and lower in patients who had a strong tuberculin skin test reaction.

Investigation of knowledge of asthma and inhaler devices in pharmacy workers.

Abstract Objective: Effective management of asthma requires the development of a partnership between the patient and his or her health care professionals. In a number of countries, including Turkey, pharmacy workers are the last link in the asthma therapy chain and usually give information to their patients about the use of these drugs and asthma. As a result, we investigated knowledge of asthma and the use of inhaler devices in pharmacy workers in Istanbul pharmacies. Methods: The study was performed with 266 pharmacists and 261 pharmacist assistants selected from 4221 pharmacies in Istanbul by random sampling, with a 90% confidence interval. Each patient was asked to fill out a questionnaire that measured their knowledge of asthma. They were also asked to demonstrate how to use the inhaler devices. Results: The high number of incorrect answers to the 11th question, that ‘‘the majority of upper respiratory tract infections triggering asthma are viral’’, may be a contributor to the unnecessary use of antibiotics in Turkey (incorrect answers from 41.2% of pharmacists and 34.5% of pharmacist assistants). Scores for inhalation device techniques for the pharmacists were as follows: metered-dose inhaler (MDI), 4.9 ± 3.9; discus, 4.4 ± 3.7; aerolizer, 4 ± 3.1; and turbuhaler, 3.8 ± 2.9. Conclusions: Istanbul pharmacy workers have limited knowledge about asthma and inhaler devices and need further education, which may contribute to improved asthma control in Turkey.

Bacterial colonization and associated factors in patients with bronchiectasis

Objectives: To evaluate the bacterial colonization and associated risk factors in patients with bronchiectasis. Methods: A total of 121 patients followed at the Bronchiectasis Unit, between 1996 and 2013 and diagnosed as having noncystic fibrosis bronchiectasis with high resolution computed tomography or multi-slice computed tomography were included in this retrospective study. The following definition of colonization was used for study purposes: Detection of at least two isolates of an organism separated by at least 3 months in a year. Results: Of these 121 patients, 65 (54%) were female and 56 (46%) were male. Mean age was 50.6 ± 16.1 years. Mean duration of illness was 20.3 ± 15.5 years. 43 (35.5%) cases had colonization. The major pathogens responsible for colonization were Pseudomonas aeruginosa (n = 25; 20.6%) and Haemophilus influenzae (n = 14, 11.5%). The stepwise logistic regression analysis showed a significant association between colonization and a low percentage of forced vital capacity (FVC%) and the presence of cystic bronchiectasis (P < 0.05). Conclusion: The following factors have been found to be associated with colonization in patients with bronchiectasis: Low FVC% and the presence of cystic bronchiectasis.

Development of eosinophilic granulomatosis with poliangiitis (Churg-Strauss syndrome) and brain tumor in a patient after more than 7 years of omalizumab use: A case report

Omalizumab is a monoclonal anti-immunoglobulin E antibody used for the treatment of severe perennial allergic asthma. Previous reports have suggested that omalizumab treatment can be associated with the development of eosinophilic granulomatosis with poliangiitis (EGPA) (formerly known as Churg-Strauss syndrome) and an increased risk of malignancy. Long-term risks of omalizumab treatment are not very well defined. Here, we report the case of a 75-year-old woman with concurrent occurrence of EGPA and brain tumor after more than 7 years of omalizumab treatment. The possibility of EGPA should be borne in mind during long-term treatment with omalizumab. Despite the absence of definitive data, an association may also exist between the development of malignancy and omalizumab use.

Bronchus Associated Lymphoid Tissue Lymphoma Presenting with Immunodeficiency and Multiple Pulmonary Nodules

Bronchus Associated Lymphoid Tissue Lymphoma (BALTOMA) is a rare subgroup of pulmonary non-Hodgkins lymphomas (NHLs) comprising less than 1% of all cases. It constitutes 3.6% of all extranodal lymphomas and only 0.5–1% of primary pulmonary malignancies. They are usually low grade B-cell lymphomas and are considered to originate from the mucosa associated lymphoid tissue (MALT) of the bronchi. Here, we represent a rare case of BALTOMA presenting with immunodeficiency and multiple pulmonary nodules.

A Simple Measure to Assess Hyperinflation and Air Trapping: 1-Forced Expiratory Volume in Three Second / Forced Vital Capacity

Background: Several recent studies have suggested that 1 minus-forced expiratory volume expired in 3 seconds / forced vital capacity (1-FEV3/FVC) may be an indicator of distal airway obstruction and a promising measure to evaluate small airways dysfunction. Aims: To investigate the associations of 1-FEV3/FVC with the spirometric measures and lung volumes that assess small airways dysfunction and reflects hyperinflation and air trapping. Study Design: Retrospective cross-sectional study. Methods: Retrospective assessment of a total of 1110 cases who underwent body plethysmographic lung volume estimations between a time span from 2005 to 2012. Patients were assigned into two groups: firstly by FEV1/FVC (FEV1/FVC <70% vs. FEV1/FVC ≥70%); secondly by FEV3/FVC < lower limits of normal (LLN) (FEV3/FVC < LLN vs. FEV3/FVC ≥ LLN). Spirometric indices and lung volumes measured by whole-body plethysmography were compared in groups. Also the correlation of spirometric indices with measured lung volumes were assessed in the whole-study population and in subgroups stratified according to FEV1/FVC and FEV3/FVC. Results: Six hundred seven (54.7%) were male and 503 (45.3%) were female, with a mean age of 52.5±15.6 years. Mean FEV3/FVC and 1-FEV3/FVC were 87.05%, 12.95%, respectively. The mean 1-FEV3/FVC was 4.9% in the FEV1/FVC ≥70% group (n=644) vs. 24.1% in the FEV1/FVC <70% group (n=466). A positive correlation was found between 1-FEV3/FVC and residual volume (r=0.70; p<0.0001), functional residual capacity-pleth (r=0.61; p<0.0001), and total lung capacity (r=0.47; p<0.0001). 1-FEV3/FVC was negatively correlated with forced expiratory flow25-75 (r=−0.84; p<0.0001). The upper limit of 95% confidence interval for 1-FEV3/FVC was 13.7%. 1-FEV3/FVC showed significant correlations with parameters of air trapping and hyperinflation measured by whole-body plethysmography. Importantly, these correlations were higher in study participants with FEV1/FVC <70% or FEV3/FVC < LLN compared to those with FEV1/FVC ≥70% or FEV3/FVC ≥ LLN, respectively. Conclusion: 1-FEV3/FVC can be easily calculated from routine spirometric measurements. 1-FEV3/FVC is a promising marker of air trapping and hyperinflation. We suggest that 1-FEV3/FVC is complementary to FEV1/FVC and recommend clinicians to routinely report and evaluate together with FEV1/FVC during spirometry.

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.

SAT0140 How Correct are the Assumptions Made During the Development of Tuberculosis Screening Algorythms Before TNF-Alpha Antagonists?

Background BCG vaccination is thought to cause false positive PPD and concomitant medications to cause false negative PPD results when screening patients before starting TNF-alpha antagonists. Moreover it is assumed that INH is difficult to tolerate in this patient group. However there is a long time between BCG vaccination and TNF-alpha antagonist use in most of the rheumatology patients; there is no consistent data to show that medications cause negative PPD results; and INH is usually well tolerated by most of our patients. Objectives To determine whether BCG vaccination causes false positive PPD, concomitant medications cause false negative PPD and whether INH is difficult to tolerate in these patients. Methods We included adult patients who were prescribed a TNF-alpha antagonist for the first time between January 2010 and December 2012 in our clinic. Patients who had a history of active tuberculosis were excluded. BCG vaccination was determined by checking for BCG scars. We used logistic regression to analyse the determinants of a positive PPD (≥5 mm). The variables were having a BCG scar, each medication, age, gender, diagnosis and disease duration. We also evaluated the frequency of being able to complete 9 months of INH treatment and the reasons for discontinuation. Results A TNF-alpha antagonist was started in 1229 patients (613 men, 616 women, mean age 39.53±13.82 years, disease duration 6.49±6.87 years). We excluded 136 patients who had previously used a TNF-alpha antagonist, 21 patients younger than age 18 and 41 patients who had previous tuberculosis treatment. Among the remaining 1031, an initial PPD test was available in 873, and QTF in 215 patients. At least one BCG scar was present in 757 patients. Multivariate regression analysis showed that BCG vaccination and male sex were associated with PPD positivity (OR=3.21, 95%CI 1.87-5.52, p<0.001; and OR=2.51, 95%CI 1.78-3.53, p<0.001 respectively), while azathioprine use was associated with a negative PPD (OR=0.50, 95%CI 0.27-0.93, p=0.029). 482/565 (85.30%) patients completed 9 months of treatment, 30 with interruptions and 34 with mild transaminase elevations not requiring interruption. 69 (12.21%) had to stop INH after 3.43±2.27 months. The reasons were hepatotoxicity in 31, non-willingness in 13, allergic dermal reactions in 6, nausea in 2, dizziness in 2, pregnancy in 1, shortness of breath in 1 and pancreatitis in 1 patient. Twelve patients stopped taking INH after their TNF-alpha therapy was stopped. Among the 31 who had to stop INH for transaminase elevation 7 were using concomitant methotrexate. None of the patients developed tuberculosis during our follow-up of up to 3 years. Conclusions BCG vaccination may still be a cause of false positive PPD in candidates for treatment with TNF-alpha antagonists. Azathioprine seems to be associated with negative PPD. INH prophylaxis is generally well tolerated despite concomitant methotrexate. Disclosure of Interest None declared