Birce Sunman

Background. Flexible bronchoscopy (FB) is widely used in children with atelectasis; however, the optimal timing of FB and the influence of underlying disease on radiographic resolution remain uncertain. We aimed to describe bronchoscopic and microbiological findings, subsequent management changes, radiographic outcomes, and factors associated with atelectasis resolution in children who underwent FB. Methods. This retrospective cohort included 108 children (0–18 years) who underwent FB for atelectasis between 2017 and 2022 with chest radiograph-based follow-up. Outcomes were immediate radiographic response and final radiographic status. An exploratory Cox model assessed time to complete resolution and included detection-to-FB interval, macroscopic pathological findings, congenital heart disease, primary ciliary dyskinesia, immunodeficiency, asthma and cystic fibrosis. Results. Median age at FB was 4.9 years (IQR: 2.5–8.8; range: 14 days to 18 years). 67/108 patients (62.0%) had underlying disorders. Macroscopic pathological findings were observed in 95.4%. Bronchoalveolar lavage cultures were positive in 75/105 patients (71.4%) and additional treatment was administered in 67/108 patients (62.0%). At final radiographic status, complete, partial, and no resolution were observed in 44/108 (40.7%), 30/108 (27.8%), and 34/108 patients (31.5%), respectively. In the exploratory Cox model, each 30-day increase in detection-to-FB interval was associated with a lower hazard of complete resolution (HR: 0.88, 95% CI: 0.80–0.98; p=0.018), but this association was attenuated after excluding intervals >365 days (p=0.169). Procedure-related complications occurred in 4/108 patients (3.7%). Conclusions. In selected children undergoing FB for atelectasis, bronchoscopy frequently revealed clinically relevant bronchoscopic and microbiological findings, informed subsequent management, and was followed by partial or complete radiographic resolution in more than two-thirds of patients. Although the timing-related findings should be interpreted cautiously, particularly because the association was attenuated in sensitivity analysis, this study supports the role of FB as a complementary diagnostic and management-guiding tool in pediatric atelectasis.

Although several studies have demonstrated an independent association between obstructive sleep apnea (OSA) and insulin resistance, the evidence remains inconsistent. We aimed to investigate the relationship between the presence and severity of OSA and insulin resistance in non-diabetic children with obesity and to explore the potential role of homeostasis model assessment-insulin resistance index (HOMA-IR) in identifying children at higher risk for OSA. Children with obesity aged 6–18 years who underwent polysomnography were retrospectively analyzed. Patients with diabetes, neuromuscular disorders, craniofacial anomalies, or those receiving treatment affecting insulin sensitivity were excluded. Age, sex, BMI, and oral glucose tolerance test (OGTT) results were extracted from medical records, and HOMA-IR was calculated. Patients were divided into two groups based on their obstructive apnea–hypopnea index (OAHI): < 2 and ≥ 2 events/h. ROC analysis was performed for HOMA-IR to determine the optimal cutoff value for identifying patients with OSA. A total of 90 children with obesity were enrolled, among whom 39 (43.3%) had OSA. The groups were comparable in terms of age and sex. Median HOMA-IR values were significantly higher in the OSA group (p = 0.014). Total OAHI showed moderately positive correlation with HOMA-IR (ρ = 0.325, p = 0.002), and baseline insulin levels measured during OGTT (ρ = 0.323, p = 0.002). In multiple linear regression analysis, HOMA-IR remained independently associated with OSA severity after adjustment for age, sex, BMI z-score, sleep efficiency, and pubertal status (β = 0.691, p = 0.025). ROC analysis identified a HOMA-IR cutoff of 3.39, with 72% sensitivity and 59% specificity for OSA. Conclusion: HOMA-IR was independently associated with OSA severity in children with obesity, suggesting that insulin resistance may serve as a useful adjunct marker for identifying patients at higher risk and prioritizing PSG evaluation. What is Known: • Childhood obesity is strongly associated with both obstructive sleep apnea (OSA) and insulin resistance. Whether insulin resistance contributes to OSA risk beyond the effect of obesity remains controversial. • Access to polysomnography (PSG) is limited, creating an unmet need for practical tools to identify children at greatest risk for OSA. What is New: • To our knowledge, this is the first pediatric study to evaluate HOMA-IR as a tool for identifying children with obesity at increased risk of obstructive sleep apnea and to propose a clinically applicable HOMA-IR threshold for prioritizing polysomnography referral. • In non-diabetic children with obesity, insulin resistance was independently associated with OSA severity, regardless of obesity, pubertal status, and other clinically relevant confounders. Children with HOMA-IR ≥ 3.39 had a substantially greater burden of obstructive sleep apnea. These findings support HOMA-IR as a simple, widely available biomarker that could help prioritize children with obesity for PSG evaluation and improve risk stratification in pediatric sleep medicine.

Tumor necrosis factor-alpha (TNF-α) inhibitors increase the risk of developing active tuberculosis (TB) disease through reactivation of latent TB infection (LTBI). We aimed to analyze TB infections in BCG-vaccinated children and adolescents with rheumatologic diseases treated with TNF-α inhibitors in a country of moderate risk for TB. This retrospective study included 261 children with a rheumatic disease who were treated with TNF-α inhibitors and followed up on a fixed schedule between January 2018 and December 2022. Demographic and clinical characteristics, as well as TB screening results, were recorded. The mean age of the patients was 14.0 ± 4.1 years; 56.7% were female. The mean age at initiation of TNF-α inhibitors was 11.0 ± 5.1 years, the mean duration of TNF-α inhibitor use was 4.1 ± 2.7 years, and the mean follow-up time was 4.1 ± 2.6 years. During the study period, 75 (29.0%) patients were diagnosed with LTBI: 44% at the initial evaluation and 56% during follow-up. None of them progressed to TB disease. Only two cases of active TB disease were seen without prior documented LTBI. Age and duration of TNF-α inhibitor use were significantly associated with LTBI positivity. Conclusion : TB screening is necessary in children and adolescents at the initiation of and during TNF-α inhibitor therapy. The risk of LTBI positivity increases with age and longer use of TNF-α inhibitors. No cases progressed from LTBI to active TB, which may support the effectiveness of current screening and prophylaxis strategies in our country. What is Known: • TNF-α inhibitors are associated with an increased risk of developing active tuberculosis (TB) disease as a result of the reactivation of latent TB infection (LTBI). What is New: • Screening for LTBI at initiation and during TNF-α inhibitor treatment, along with appropriate LTBI prophylaxis, prevented LTBI reactivation into active TB disease in BCG-vaccinated patients receiving TNF-α inhibitors. • Increasing age and duration of TNF-α inhibitor treatment are associated with the risk of LTBI positivity.

Background: Modulators have revolutionized cystic fibrosis (CF) management, but their effects on respiratory pathogens remain unclear. This study evaluated changes in lower respiratory tract pathogen detection after modulator therapy in children with CF, registered in the Cystic Fibrosis Registry of Turkey. Method: This retrospective, multicenter cohort study included children receiving modulator therapy between 2020 and 2022. Chronic respiratory tract colonization rates before and after therapy were compared, along with inhaler treatments, oral steroid, azithromycin use, pulmonary function tests, and hospitalizations for pulmonary exacerbations. The cohort was stratified by age, modulator type, and lung disease severity. Changes in microbiologic data over a 1‐year period were also analyzed for children not receiving modulator therapy. Results: A total of 101 children (mean age 9.95 ± 4.44 years) were included. Following modulator therapy, respiratory cultures of 57 (56.4%) were negative. Among 32 children with chronic Pseudomonas aeruginosa ( P. aeruginosa ) colonization, 14 (44%) showed negative respiratory cultures after receiving modulator therapy ( p = 0.039). Conversion to culture‐negative status was significant for methicillin‐sensitive Staphylococcus aureus (MSSA) ( p = 0.022) and methicillin‐resistant Staphylococcus aureus (MRSA) ( p = 0.034), with ETI therapy yielding the highest conversion rates. Inhaled antibiotic use for chronic respiratory pathogens decreased significantly ( p = 0.039), and spirometry parameters improved ( p < 0.001). Among 1232 children not receiving modulators, 180 (14.6%) had negative respiratory cultures when examined at 1‐year interval. In the same group, intermittent/chronic P. aeruginosa colonization was negative in 58 cases, while 85 developed new growth, following modulator therapy, with positivity rates rising from 16.3% to 18.5% ( p = 0.030). No significant changes in other pathogen detection were observed. Conclusion: Modulators, particularly ETI, reduced respiratory pathogen detection and improved lung function in children with CF.

Background: Lower airway malacia (LAM) is characterized by excessive collapsibility of the airway during expiration. Although flexible bronchoscopy is widely employed for diagnosis, it is prone to Interobserver variability and technical limitations. This study aims to evaluate intra‐ and Interobserver consistency in diagnosing LAM in pediatric patients using dynamic flexible bronchoscopy and to assess the impact of bronchoscope size and observer training on diagnostic agreement.Methods: Pediatric patients who underwent fiberoptic flexible bronchoscopy for dynamic evaluation of LAM were included in this study. A total of 100 anonymized video recordings (50 with diagnosed with LAM and 50 classified as normal) were randomly selected for review. Six pediatric pulmonology specialists independently evaluated these recordings for the presence of LAM, including tracheomalacia (TM) and bronchomalacia (BM), using standardized diagnostic criteria. Interobserver and intra‐observer consistency were assessed through statistical analysis with Cohen's Kappa coefficient.Results: Intraobserver consistency for diagnosing LAM ranged from substantial to almost perfect (0.675 to 0.857). Interobserver consistency was moderate to substantial (0.583 to 0.689), showing the highest agreement for TM when using the 2.8 mm bronchoscope. Center 1, where evaluations were conducted by a single trainer, demonstrated higher Interobserver consistency (0.606 to 0.689) than Center 2, which involved multiple trainers (0.502 to 0.562). The agreement was notably lower for BM, especially within the intermediate bronchi.Conclusion: The observed variability in diagnostic consistency highlights the critical need for standardized diagnostic guidelines, which could improve treatment outcomes for pediatric patients with LAM.

To evaluate the effects of telerehabilitation (TG) compared with an unsupervised home exercise training program (HG) on muscle function, physical activity (PA), and sleep in children with cystic fibrosis (CF). Thirty children with CF (mean age = 10.2 ± 1.9 years) were randomly allocated to TG or HG. The exercise protocol was applied thrice a week for six weeks in the TG via Skype. The same exercises were sent in an exercise booklet to the HG, and phone contact was made once a week. Muscle function (one-minute sit-to-stand (1-min STS), sit-up, pushup, squat, and plank tests)), PA (Physical Activity Questionnaire for Older Children), and sleep (Epworth Sleepiness Scale (ESS) and Pediatric Sleep Questionnaire (PSQ)) were assessed before and after the 6-week study period. The 1-min STS significantly improved in the TG compared with the HG (p ≤ .001, η_p² = 0.474). The sit-up (p = .005, η_p² = 0.247), pushup (p = .002, η_p² = 0.180), squat (p = .002, η_p² = 0.284), and plank (p < .001, η_p² = 0.360) test scores were significantly improved in the TG compared to the HG. No significant changes between groups were seen for PA (p = .261, η_p² = 0.045), ESS (p = .160, η_p² = 0.069), or PSQ (p = .763, η_p² = 0.003). Children who received TG improved muscle function more than children who received an HG. The effectiveness of longer term TG programs should be investigated in children with CF.