<abstract>
<title style='display:none'>Abstract</title>
<sec><title style='display:none'>Background</title>
Exudative pleural effusions are often challenging, and on many occasions remain undiagnosed. Hence, a blind closed needle pleural biopsy (CNPB) is extremely relevant against this background.
</sec>
<sec><title style='display:none'>Methods</title>
We conducted a prospective study, in which a CNPB using a Cope’s needle was done in patients with exudative pleural effusion. Data were analysed using SPSS software.
</sec>
<sec><title style='display:none'>Results</title>
Our study included 250 patients, of which 140 (56%) were males and 110 (44%) female. 218 (87.2%) had tubercular effusion 22 (8.8%) had effusion secondary to malignancy, 8 (3.2%) had synpneumonic effusions, and 1 (0.4%) each had effusion secondary to pancreatitis and rheumatoid arthritis (RA). AFB culture was positive in 50 (22.4%) on pleural fluid, as compared to 209 (87%) on pleural biopsy. CBNAAT detected MTB in 34 (14%) on pleural fluid as compared to 72 (28.8%) on pleural biopsy. Caseous granuloma was found in 184 (73.6%). The sensitivity for AFB culture using CNPB tissue and pleural fluid was 95.8% and 22.5%, respectively (P &lt; 0.05). Drug susceptibility testing (DST) done on pleural tissue divided our patients as drug sensitive 182 (87%), MDR 13 (6.2%), preXDR 12 (5.7%), and XDR TB 2 (0.9%). For malignancy, sensitivity of pleural fluid and pleural biopsy was 9% and 63%, respectively (P &lt; 0.05). Major complications of the procedure were pain in 25 (10%), pneumothorax in 15 (6%), and haematoma in 8 (3%). Of the patients who developed pneumothorax, only one patient required intervention with an intercostal drain, and the rest resolved spontaneously.
</sec>
<sec><title style='display:none'>Conclusion</title>
CNPB is an easy, quick, cost-effective, and reliable method that can be used for diagnosing exudative pleural effusions of indeterminate aetiology in the out-patient setting.
</sec>
</abstract>

Diagnostic utility of closed needle pleural biopsy in exudative pleural effusions

<abstract>
<title style='display:none'>Abstract</title>
Cough is a natural defence mechanism of the lungs to prevent aspiration and to keep the airway clean. Cough, wheezing and shortness of breath are common symptoms of asthma. Cough-variant asthma is one of the phenotypes of asthma with the main symptom of cough without shortness of breath and wheezing. Cough-variant asthma is largely observed in patients with bronchial hyperresponsiveness who experience cough due to innocuous stimuli, and it is associated with a family history and seasonal allergy. In the present study, in patients with cough-variant asthma, no abnormalities were found during the lung function test, particularly forced expiratory flow in the first second (FEV1) or peak expiratory flow (PEF), although these values were lower than those in normal individuals. A bronchial provocation test using methacholine is needed to assess airway hyperresponsiveness, and depending on the outcome of the test, an assessment can be made as to the probability of the patient requiring a diagnosis of cough-variant asthma. Administration of inhalation therapy with bronchodilators and corticosteroids is the mainstay of management in patients with cough-variant asthma presenting with the symptom of persistent cough. Until now, there have been no specific guidelines for drug selection, dose and duration of inhaled corticosteroid use in cough-variant asthma. If symptoms do not resolve with inhaled corticosteroid monotherapy, consideration may be given to increase the inhalation dose or to add other drugs such as long-acting B2 agonists, slow-release theophylline or leukotriene receptor antagonist (LTRA).
</abstract>

Diagnosis and management of cough-variant asthma

<abstract>
<title style='display:none'>Abstract</title>
<sec>
<title style='display:none'>Objective</title>
To identify essential competencies required for equipping pulmonologists to manage respiratory diseases such as the Covid-19 pandemic.
</sec>
<sec>
<title style='display:none'>Methods</title>
A descriptive and qualitative study was conducted. Focus group, which consisted of five Syrian members who were affiliated with the Syrian Association of Thoracic Medicine and Surgery were invited to formulate a preliminary list of competencies. Delphi technique with three cycles was also employed to evaluate the resulted list. The number of pulmonologists who accepted to take part was 67 out of 110. All competencies suggested by at least 80% of experts were included in the final list. Reliability was tested using Cronbach’s alpha, Descriptive statistics including Mean and standard deviation were performed.
</sec>
<sec>
<title style='display:none'>Findings</title>
Forty-five essential competencies were identified including ten competencies in cognitive domain, 11 skills, and 24 competencies related to attitude domain.
</sec>
<sec>
<title style='display:none'>Conclusion</title>
A list of 45 competencies has been identified. It is hoped that they will guide and enable pulmonologists to provide the best health care to patients with respiratory infections, especially during the COVID-19 pandemic. It will also guide decision makers to design training programs that can address these competencies.
</sec>
</abstract>

A framework for the identification of competencies required from Syrian pulmonologists during COVID-19 pandemic

<abstract><title style='display:none'>Abstract</title>With the advent of computed tomography (CT) in respiratory medicine, a greater delineation of the respiratory structures has been possible in the two-dimensional space. The various CT techniques used by pulmonologists include the high-resolution computed tomography (HRCT) thorax with expiratory scans, contrast-enhanced CT (CECT) thorax, CT thorax, CT pulmonary angiography (CTPA) and rarely a CT aortography/angiography. Each of the imaging techniques presents stronger and weaker points. In this paper, radiological lesions are classified according to their location. Such abnormalities are observed in the airways, in the lung parenchyma, in the interstitium and last but not least in the pleura. The review mainly addresses radiological lesions with higher specificity because they are key elements in establishing a definitive diagnosis. In conclusion, performing a chest CT is vital in the diagnosis and management of respiratory conditions.</abstract>

Common pulmonary computed tomography signs and their clinical relevance: A review

<abstract>
<title style='display:none'>Abstract</title>
<bold>Background:</bold> Central nervous system (CNS) tuberculosis (TB) accounts for 1% of all cases of TB and is a major cause of mortality and morbidity. Cerebral tuberculomas represent 30% of CNS TB and is a diagnostic challenge.
<bold>Case presentation:</bold> A 42-year-old male patient, known with alcoholic cirrhosis, performs a cerebral computer tomography (CT) after a lipothymic episode accompanied by right hemiparesis, which showed multiple parenchymal ring-lesions (inflammatory-infectious substrate/secondary tumours). Subsequently, the thoracic-abdominal-pelvic-CT-scan reveals micronodular diffuse pulmonary infiltrate and right pleural effusion. Cerebral Magnetic resonance imaging (MRI) describes bilateral infra/supratentorial lesions, raising the suspicion of tuberculomas. HIV serology was negative, cerebrospinal fluid showed no pleocytosis, but high protein level, pleural lymphocytosis in the pleural effusion and positive GeneXpert test in bronchial aspirate. The diagnosis of military TB with cerebral tuberculomas was established. The outcome was favourable under antituberculous treatment initially associated with corticosteroids. At two months the patient had a significant improvement in pulmonary lesions, but while some cerebral lesions decreased in size other lesions increased (paradoxical reaction). At the 14-month end-of-treatment re-evaluation there was an important regression in number and size of the brain lesions.
<bold>Conclusions:</bold> The diagnosis of cerebral tuberculoma remains a challenge for the clinician due to non-specific clinical and radiological findings. The survival rate is over 80% with early diagnosis and correct treatment.
</abstract>

Cerebral tuberculosis - a diagnostic challenge

<abstract><title style='display:none'>Abstract</title>Pulmonary nodules are single or multiple rounded opacities with a size of minimum 1 cm diameter visualised in the lung parenchyma. From an anatomopathological point of view, they can be benign or malignant. Most often, these nodules are asymptomatic or with minimal symptoms. Now, we present the case of a 62-year-old patient, a smoker, with exposure to occupational respiratory noxious (cellulose industry – 10 years and printing industry – 30 years) without significant personal respiratory pathological history. He has dyspnoea on moderate exertion, irritable cough, myalgia, arthralgia and physical asthenia. The physical examination reveals the presence of a right bayonet sign. Biologically, an inflammatory syndrome was present, the urine test shows no pathological changes, but the imaging is intriguing. On the other side, the imagistic workup [chest X-ray and computed tomography (CT) scan] was quite surprising: micro/macronodular opacities with variable wall thickness, irregular contours and a tendency to confluence at the bilateral lower lobes level. A bronchoscopy was also performed with bronchioloalveolar lavage (BAL) in the right upper lobe (RUL) and bronchial biopsy at the level of the right upper ventral. The hypotheses are multiple: pulmonary rheumatoid nodules, polyangiitis with granulomatosis, lymphangitis carcinomatosis and tuberculosis. Thoracic surgery determined the diagnosis.</abstract>

The unpredictable diagnosis of pulmonary nodules

<abstract>
<title style='display:none'>Abstract</title>
The pandemic of the coronavirus disease 2019 (COVID-19) has affected millions of people worldwide. Patients can develop a lot of different manifestations, from asymptomatic form to severe acute respiratory distress syndrome (ARDS). Pulmonary fibrosis, as a primary cause of mortality, is the main consequence of lung injury caused by acute respiratory distress syndrome. Unfortunately, effective treatment for pulmonary fibrosis has not yet been found; that’s why we found an essential anti-fibrotic agent in the early acute phase of severe COVID-19 to fight the infection outcomes. This narrative review presents the therapeutic strategy and the importance of fighting pulmonary fibrosis to help patients worldwide protect themselves against severe and fatal viral infections. To prevent long-term sequelae and early mortality, it’s necessary to test the efficacy of anti-inflammatory drugs.
</abstract>

Nintedanib: beneficial agent in post-COVID-19 Pulmonary Fibrosis

<abstract>
<title style='display:none'>Abstract</title>
Pneumocystis jirovecii pneumonia, previously known as Pneumocystis carinii Pneumonia (PCP), is a fungal infection most commonly encountered in immunocompromised patients and, in some cases, can be life-threatening. Patients at risk include those with cancer, HIV positive, transplant recipients, and those under immunosuppressive therapies. There are no specific signs or symptoms for PCP and its differential diagnosis includes other viral or bacterial pneumonias and also Tuberculosis, the latter especially in high endemic areas. We present the case of a 32 year-old female patient who presented to the hospital for dyspnea and cough, treated for Pulmonary Tuberculosis, and eventually diagnosed with Pneumocystis Pneumonia, in spite of her multiple false-negative HIV tests.
</abstract>

Pneumocystis Pneumonia misdiagnosed as Pulmonary Tuberculosis in a patient with repeatedly false-negative HIV tests

<abstract>
<title style='display:none'>Abstract</title>
In the field of medical imaging, techniques like computed tomography (CT), magnetic resonance imaging (MRI), and X-rays are essential for diagnosing and monitoring diseases, particularly in pulmonary pathology. A significant development in this area is the application of automated segmentation and machine learning, enhancing the accuracy in diagnosing lung diseases, such as lung cancer. However, there remains a knowledge gap in fully understanding the potential and limitations of these technologies, especially across diverse clinical conditions and datasets. To address this gap, the paper delves into the integration of artificial intelligence with conventional imaging techniques, focusing primarily on the use of convolutional neural networks (CNNs) and transformer-based models in automated segmentation. This approach is pivotal in improving the detection rates and accuracy of diagnoses in complex pulmonary diseases. Findings indicate that AI-enhanced imaging significantly advances the early detection of pulmonary diseases, notably lung cancer, and reduces the time until diagnosis. Yet, challenges such as the necessity for diverse and comprehensive training data and the generalizability of algorithms, persist. Moreover, ethical considerations in the deployment of AI technologies in healthcare are crucial. In conclusion, while these technologies mark substantial progress in pulmonary imaging, it is essential to find the balance between technological advancements and ethical considerations. This balance is key to ensuring effective and equitable healthcare, maximizing the benefits of AI in medical imaging while maintaining patient trust and privacy.
</abstract>

Enhancing Pulmonary Care: The Pivotal Role of Segmentation and Automated Analysis in Advanced Pulmonary Imaging

<abstract>
<title style='display:none'>Abstract</title>
<sec><title style='display:none'>Introduction</title>
The immune response in patients with SARS-CoV2 infection is an incompletely elucidated pathophysiological challenge. There are more and more cases in which COVID-19 vaccination induces autoimmune side effects, of course, in a selected population. What are the criteria that induce such a response? How can it be prevented? These are questions that the medical world must answer.
</sec>
<sec><title style='display:none'>Material and Methods</title>
A 28-year-old male patient presented with repeated small hemoptysis accompanied by pleuritic pain, which started suddenly 2 days prior. From the patient’s history, we note autoimmune thyrotoxicosis triggered by the administration of the second dose of the anti-SARS-CoV2 vaccine, but also a recent COVID-19 episode. At the time of hospitalization, slightly elevated serum values of D-dimers were noted, and the CT examination identified multiple unilateral filling defects in the middle and small right pulmonary arteries, accompanied by a ground-glass opacity suggestive of a pulmonary infarction and possible bilateral stenosis of the subclavian arteries. The extended immunological panel was negative, but genetic tests have identified two thrombophilic gene mutations. Functionally, a discrete decrease in lung volumes and a slight impairment of alveolo-capillary diffusion was observed. The clinical, imaging and functional evolution was favorable under anticoagulant treatment.
</sec>
<sec><title style='display:none'>Discusions</title>
The predisposition for thrombosis in COVID-19 is determined by at least two distinct processes, subsegmental and segmental vessel occlusion and microvascular in situ immunothrombosis. Pulmonary thromboembolism occurs more frequently in the first weeks after diagnosis, but cases farther from the acute moment have also been reported in literature, including in patients with mild forms of the disease.
Certain adjuvant components of the vaccines, as well as the SARS-CoV2 virus itself, can trigger autoimmune reactions in genetically predisposed individuals.
</sec>
<sec><title style='display:none'>Conclusion</title>
Patients with active or recently recovered COVID-19 should be considered at an increased risk of pulmonary embolism when they present with specific symptoms, even without the existence of other risk factors.
</sec>
</abstract>

Autoimmunity in context of exposure to SARS-Cov2 virus

<abstract>
<title style='display:none'>Abstract</title>
Pulmonary embolism (PE) is defined by the obstruction of pulmonary arteries by thrombi or emboli (malignant, grease, air). Most frequently, thrombi arise from deep veins of lower limbs. Pulmonary embolism is a medical emergency with a high death risk. Early mortality is high, sudden death occurs in about a quarter of the patients. On long term, it can lead to post-embolic pulmonary hypertension and recurrent pulmonary embolia. The high risk of death in acute phase and on long-term depends on the severity of the acute phase, on the recurrence, and on the co-morbidities. PE can be the first manifestation of on occult malignancy, or it may complicate an already diagnosed cancer.
We present a retrospective analysis on PE associated to malignancy, on 106 patients, with classic anticoagulant treatment (low weight molecule heparin and/or antivitamin K agents) or novel oral anticoagulants (NOAC) and compare the early and late mortality associated to PE and anticoagulant treatment. Our observations note a higher percentage of recurrences but significantly lower mortality in patients treated with NOAC as compared to classic treatments.
</abstract>

The anticoagulant treatment dilemma in pulmonary embolism associated to cancer

<abstract>
<title style='display:none'>Abstract</title>
<sec><title style='display:none'>Introduction</title>
Despite the evolving knowledge about COVID-19 convalescents, there is still not enough data to validate simple methods of identifying the non-improvers. Our objective: to look for bad prognostic factors in long-COVID.
</sec>
<sec><title style='display:none'>Methods</title>
We conducted a prospective observational study among previously hospitalized patients with COVID-19. Individual characteristics were gathered and pulmonary function tests - spirometry and lung transfer for carbon monoxide (TL,CO) – were performed twice, approximately one and three months after hospitalization from COVID-19. Control radiological examinations were repeated and compared at the time of the study.
</sec>
<sec><title style='display:none'>Results</title>
After dividing the study group (30 patients) according to improvement in forced vital capacity (FVC) and/or TL,CO we observed that the forced expiratory volume in the first second (FEV1) acquired from spirometry accurately indicates clinical improvement with the area under the curve (AUC) of 0.892 (95% CI 0.73 – 1). Notable differences were found in estimated total lung capacity (eTLC) and radiological score as well.
</sec>
<sec><title style='display:none'>Conclusions</title>
Our findings suggest that simple spirometry with FEV1 assessment performed in the post-COVID period helps select individuals with impaired recovery that should presumably be referred to a respiratory specialist and pulmonary rehabilitation.
</sec>
</abstract>

The use of simple pulmonary function tests in the post-COVID-19 pulmonary improvement prediction: lessons from a single-center study

<abstract><title style='display:none'>Abstract</title>Tuberculosis (TB) is still a leading cause of morbidity and mortality worldwide. The impact on patient’s life is significant, leading to physical, mental and social deconditioning, not only in active TB but also in post TB sequela. Although with specific antituberculous treatment sputum negativity can be achieved, TB extrapulmonary symptoms such as cachexia, muscle weakness and depression may persist for a long time.The pulmonary rehabilitation (PR) may be a useful tool in this patient’s therapy in active and also in sequela phase. The benefits of PR are: reducing symptomatology, improving the degree of functional independence and quality of life, and increasing the ability to perform daily activities. This article discusses the components of a PR programme in active TB and TB sequela, and the results obtained by studies so far.</abstract>

Pulmonary rehabilitation and tuberculosis: a new approach for an old disease

<abstract><title style='display:none'>Abstract</title><sec><title style='display:none'>Background</title>Cardiovascular diseases (CVDs) are common in people with chronic obstructive pulmonary disease (COPD), and their presence is associated with an increased risk for hospitalization, longer length of stay and all-cause and CVD-related mortality. We assessed the role of angiotensin-converting enzyme (ACE) gene polymorphism in the occurrence of arterial hypertension (AH) in patients with COPD.</sec><sec><title style='display:none'>Methods</title>The study group consisted of 96 patients. Group 1 had 25 individuals with COPD, Group 2 had 23 individuals with AH and Group 3 had 28 individuals with COPD and AH. The control group consisted of 20 healthy subjects. I/D genotypes of ACE were determined by polymerase chain reaction amplification.</sec><sec><title style='display:none'>Results</title>The frequency distribution of polymorphic genotypes of the gene encoding ACE and assessment of compliance with the Hardy-Weinberg population equilibrium were carried out in groups of patients with COPD, AH and COPD + AH combination. The frequencies of the genotype responsible for I/D polymorphism of the ACE gene in the control and experimental groups were not found to deviate significantly from the Hardy–Weinberg equilibrium. The results of the study have not demonstrated any significant impact of alleles of ACE genes or ACE genes on occurrence of diseases such as COPD, AH and combinations thereof. However, analysis of odds ratio has demonstrated that the presence of the D allele of the ACE gene may increase the risk for occurrence of the COPD + AH (OR = 1.26).</sec><sec><title style='display:none'>Conclusion</title>The data obtained in the study allow suggesting that the presence of D allele of the ACE gene may increase the risk for AH in patients with COPD.</sec></abstract>

ACE gene I/D polymorphism and arterial hypertension in patients with COPD

<abstract><title style='display:none'>Abstract</title>The assessment of functional capacity is a significant part of the preoperative evaluation of patients proposed for both thoracic and abdominal surgery. The cardiopulmonary exercise test (CPET) is the most comprehensive exercise test currently used. It provides an objective assessment of the patient's training level and an individualised risk profile for complications and guides the perioperative care. This article provides a brief description of the roles of CPET in thoracic surgery. Guidelines recommend it for perioperative assessments because of its prognostic value, its utility in the postoperative period and in pulmonary rehabilitation programmes.</abstract>

Cardiopulmonary exercise testing in thoracic surgery

Summary

Asthma–COPD–Bronchiectasis combination: an unstudied triplet

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Pneumologia

 Pneumologia is the journal of the Romanian Society of Pneumology, being continuously edited since 1951. Pneumologia is an open-access journal, edited in...

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