Critical Analysis of the National Emphysema Treatment Trial Results for Lung-Volume-Reduction Surgery.

The National Emphysema Treatment Trial compared medical treatment of severe pulmonary emphysema with lung-volume-reduction surgery in a multiinstitutional randomized prospective fashion. Two decades later, this trial remains one of the key sources of information we have on the treatment of advanced emphysematous lung disease. The trial demonstrated the short- and long-term effectiveness of surgical intervention as well as the need for strict patient selection and preoperative workup. Despite these findings, the key failure of the trial was an inability to convince the medical community of the value of surgical resection in the treatment of advanced emphysema.

Prognostic scoring system and risk stratification in patients with emphysematous pyelonephritis: an 11-year prospective study at a tertiary referral centre.

OBJECTIVES: To define pre-morbid, clinical, laboratory, and imaging features and identify prognostic factors associated with morbidity and mortality in patients with emphysematous pyelonephritis (EPN) and develop a prognostic scoring system for improving management outcomes. PATIENTS AND METHODS: From January 2009 to December 2019, we performed a prospective study of all patients with a suspected diagnosis of EPN referred to a specialist tertiary centre in South India. All patients who underwent non-contrast computed tomography of the abdomen and those diagnosed with EPN were included in this study. Demographic parameters, imaging, haematological and microbiology results were recorded. Patients were divided into three groups: Group 1, patients who survived without any intervention; Group 2, those who survived with surgical intervention; and Group 3, those who died with or without intervention. A prognostic scoring system was developed from 18 different parameters and risk stratification was developed. The scores were correlated with overall prognosis. RESULTS: Data from 131 patients with EPN enrolled in the study were analysed: Group 1 (n = 22), Group 2 (n = 102) and Group 3 (n = 7). By using univariate analysis, 10 factors were identified to be significantly associated with prognosis. Diabetes mellitus was the most common comorbidity. Shock at initial admission indicated a poor prognosis and warranted immediate attention (P < 0.001). CONCLUSIONS: A multi-disciplinary approach, a high index of clinical suspicion, an early diagnosis and administration of culture-specific antibiotics with identification of prognostic indicators and risk stratification, allows prompt and appropriate medical and surgical treatments that could improve EPN management outcomes.

Emphysematous Pancreatitis in the Elderly.

BACKGROUND: Emphysematous pancreatitis (EP) is an unusual medical emergency that presents with intraparenchymal pancreatic air in the setting of necrotizing infection. We aimed to determine the differences in the epidemiology, etiology, clinical presentation, symptoms and outcome of EP between elderly and nonelderly patients. MATERIALS AND METHODS: A PubMed search was performed using the keywords "emphysematous pancreatitis," "gas-forming pancreatitis" and "pancreatitis and pneumoperitoneum" from March 1959 to February 2019. Forty-two EP articles with 58 patients were enrolled in our study. We divided the patients into ≥65 (elderly, n = 25) and <65-year age groups (non-elderly, n = 33). Data on patient age, sex, comorbidities, symptoms, clinical findings, etiologies, laboratory results, treatments, outcomes and mortality were collected and analyzed using the Student's t test and chi-square test using IBM SPSS 20. P values < 0.05 (2-tailed) indicated statistical significance. RESULTS: Alcohol- and biliary pancreatitis-related EP were 4.95- and 4-fold, respectively, more frequent in the elderly than in the nonelderly (36% versus [vs.] 9.1%, P < 0.05). Fever was more frequent in the nonelderly than in the elderly (69.7% vs. 36%, P < 0.05). The elderly presented with more severe shock status (68% vs. 33.3%, P < 0.05) and received more surgical interventions than the nonelderly (60% vs. 30.3%, P < 0.05). CONCLUSIONS: Biliary pancreatitis is the most common type of EP in the elderly and has an atypical presentation with less fever, more severe shock, and more surgical interventions. In treating elderly patients with pancreatitis, immediate administration of adequate antibiotics, assisted drainage and early surgical intervention are needed to prevent shock.

The Technome - A Predictive Internal Calibration Approach for Quantitative Imaging Biomarker Research.

The goal of radiomics is to convert medical images into a minable data space by extraction of quantitative imaging features for clinically relevant analyses, e.g. survival time prediction of a patient. One problem of radiomics from computed tomography is the impact of technical variation such as reconstruction kernel variation within a study. Additionally, what is often neglected is the impact of inter-patient technical variation, resulting from patient characteristics, even when scan and reconstruction parameters are constant. In our approach, measurements within 3D regions-of-interests (ROI) are calibrated by further ROIs such as air, adipose tissue, liver, etc. that are used as control regions (CR). Our goal is to derive general rules for an automated internal calibration that enhance prediction, based on the analysed features and a set of CRs. We define qualification criteria motivated by status-quo radiomics stability analysis techniques to only collect information from the CRs which is relevant given a respective task. These criteria are used in an optimisation to automatically derive a suitable internal calibration for prediction tasks based on the CRs. Our calibration enhanced the performance for centrilobular emphysema prediction in a COPD study and prediction of patients' one-year-survival in an oncological study.

The effect of emphysema on survival in patients with idiopathic pulmonary fibrosis: A retrospective study in Taiwan.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a rare and chronic fibrosing interstitial lung disease. However, the clinical features and outcomes of IPF in Taiwan have not been well studied. In addition, the survival difference between patients with IPF alone and combined pulmonary fibrosis and emphysema (CPFE) remains controversial. METHODS: Patients diagnosed with IPF between 2006 and 2016 were retrospectively enrolled in this study. IPF was defined according to the 2011 American Thoracic Society/European Respiratory Society guideline. The clinical features, comorbidities, and outcomes of CPFE group and IPF-alone group were compared. The extents of emphysema and fibrosis were evaluated. RESULTS: In total, 114 patients with IPF were enrolled, and 86.8% of them were men with a mean age of 77.8 years. The median survival was 3.33 years in all patients with IPF. Moreover, 30 patients (26.3%) met the CPFE criteria. The CPFE group had a higher percentage of smokers (90% vs 50%, p < 0.001), higher forced vital capacity (82% vs 59%, p < 0.001), and lower fibrosis scores (8.5 ± 2.9 vs 10 ± 3.2, p = 0.022) than did the IPF-alone group. The baseline room air saturation and percentage of pulmonary hypertension were similar between the two groups. The survival time was not significantly different between the CPFE and IPF-alone groups (median survival, 3.58 vs 2.39 years, p = 0.163). In the multivariate analysis, higher fibrosis score, room air saturation < 90%, and lung cancer were significant factors associated with mortality. CONCLUSION: Our study showed that emphysema had no significant effect on the survival of patients with IPF. The outcome of IPF was mainly determined by the baseline disease severity and other comorbidities.

Could platelet to leucocytic count ratio (PLR) predict sepsis and clinical outcomes in patients with emphysematous pyelonephritis?

OBJECTIVES: To study risk factors for sepsis and mortality evaluating the role of platelet to leucocytic count ratio (PLR) as a marker for urosepsis and clinical outcomes in cases of emphysematous pyelonephritis (EPN). MATERIALS: Patients with EPN were retrospectively reviewed. Patients' age, sex, diabetes mellitus (DM), Body Mass Index (BMI), hydronephrosis, types of EPN, air locules volume, serum creatinine, leucocytic count, and platelet count, PLR, albumin, INR and the line of treatment were analyzed as risk factors of sepsis. Correlation between PLR and other variables was done using Pearson correlation coefficient. Univariate and multivariate analyses for sepsis and mortality were performed. RESULTS: Of fifty four patients, 38 patients had SIRS ≥2 criteria on admission. Twenty patients developed sepsis requiring ICU admission. In univariate analysis, male gender, lower BMI, higher INR, higher WBCs count and lower PLR were associated with sepsis (P = 0.0001, 0.009, 0.04, 0.003 and 0.001, respectively). In multivariate analysis, PLR ≤18.4, male sex and BMI ≤24.2 were independent risk factors. Lower PLR directly correlated with serum albumin (P = 0.01) and inversely correlated with serum creatinine and random blood glucose level and Klebsiella infection (P = 0.001, 0.007 and 0.005, respectively). Also, it was correlated with a higher total score of qSOFA and SOFA (P = 0.02 and 0.04). Lower PLR was independent risk factors for death in EPN patients with (P = 0.003). CONCLUSION: EPN is associated with sepsis development. Lower PLR is an independent simple predictor for sepsis and mortality in patients with EPN.

Extended Mortality Follow-up of a Cohort of Dry Cleaners.

BACKGROUND: Dry cleaning workers are commonly exposed to tetrachloroethylene, a suspected bladder carcinogen, and other organic solvents. The health risks associated with solvent exposures in this industry are unclear. METHODS: We extended mortality follow-up of 5,369 dry cleaning union members in St. Louis to further investigate solvent-related risks. We added 22 years of follow-up, from 1993 through 2014, via linkage to the National Death Index. Using Cox proportional hazards modeling, we computed hazard ratios (HRs) and 95% confidence intervals (CIs) relating cause-specific mortality with levels of a solvent exposure index previously developed by an industrial hygienist based on workers' job titles from union records. The models were fit adjusting for age, sex, and decade of union enrollment, and assuming different exposure lags. RESULTS: In internal analyses of estimated solvent exposure with a 20-year lag, we observed exposure-response relationships for bladder cancer (HR medium exposure = 4.2; 95% CI = 0.7, 24.5 and HR high exposure = 9.2; 95% CI = 1.1, 76.7 vs. no exposure; Ptrend = 0.08) and kidney cancer (HR = 4.1; 95% CI = 0.7, 22.5 and 24.4; 2.9, 201.6; Ptrend = 0.004). High exposure was also associated with heart disease (HR = 1.6; 95% CI = 1.1, 2.2) and lymphatic/hematopoietic malignancies (HR = 4.3; 95% CI = 1.4, 13.6). CONCLUSIONS: These findings are, to the best of our knowledge, the first cohort evidence relating solvent exposure levels among dry cleaners to elevated risks of selected cancers and heart disease. Additional studies employing solvent-specific exposure assessment are needed to clarify cancer risks associated with tetrachloroethylene.

Comparing diabetic and nondiabetic emphysematous pyelonephritis and evaluating predictors of mortality.

Mortality among patients with emphysematous pyelonephritis (EPN) has reduced from 78% to 21%, yet it is one of the most serious urologic emergencies. This prospective observational study aims to study and compare clinical profile, management, and outcomes in diabetic and nondiabetic patients with EPN. All patients of EPN admitted to emergency medical services were included in the study. Patients were grouped into diabetic and nondiabetic EPN, and the eventual predictors of mortality were assessed. The mean age of patients was 55.43 years, with 36 (65.7%) female patients. Mortality was found to be 18.86%. On univariate analysis, the factors significantly associated with mortality include dyspnea at presentation, altered consciousness, blood pressure <90 systolic, oliguria, decreased platelet count (<100,000/mm[3]), urine culture positive for Escherichia coli, hyponatremia (Na <132), hyperkalemia (K >5.0), higher computerized tomography (CT) grade, and emergency nephrectomy as an intervention modality (P <0.05). Mortality was comparable among diabetics and nondiabetics. Diabetics had a lower CT score and higher creatinine (>2 mg/dL) as compared to nondiabetics. Most patients having urolithiasis were nondiabetic. Although nondiabetics had a higher CT score as compared to diabetics, the mortality in nondiabetics and diabetics was equivalent. This may suggest that either diabetics have a rapid deterioration of EPN status or intercurrent metabolic factors in diabetics may contribute to mortality among diabetics. Raised serum creatinine and immunocompromised status owing to diabetes may also play a role.

Decreased serum TRAIL is associated with increased mortality in smokers with comorbid emphysema and coronary artery disease.

BACKGROUND: Smokers are highly susceptible to lung and cardiovascular disease that can reduce their survival. Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) is a protein in the circulation that may suppress vascular and pulmonary inflammation. Therefore, we hypothesized that diminished circulating TRAIL levels would be associated with poor survival in smokers with lung and cardiovascular disease. METHODS: Serum TRAIL level was measured by immunoassay in 474 smokers. Coronary atherosclerosis was assessed by coronary artery calcium scoring along with emphysema, lung function, and survival. RESULTS: The 474 smokers were 65.7 ±â€¯6.3 years old and 52.2% male with 55.3 ±â€¯31.5 pack-years of tobacco-exposure. 83 of them died during 3588.2 person-years of follow up. At baseline, lower TRAIL level was associated with more coronary artery calcium (OR = 1.2 per SD, 95%CI 1.1-1.5, p = 0.02), and with history of myocardial infarction (OR = 2.3 per SD, 95%CI 1.2-4.5, p = 0.02), angina (OR = 1.6 per SD, 95%CI 1.1-2.6, p = 0.03), and angioplasty (OR = 1.8 per SD, 95%CI 1.0-3.1, p = 0.04) in models adjusted for cardiovascular risk-factors, FEV1, and emphysema. Also, lower TRAIL level was associated with emphysema severity independent of demographics and tobacco exposure (ß = 0.11 sq. root units, 95% CI 0.01-0.22, p = 0.03). Further, TRAIL level was lowest in smokers with comorbid emphysema and coronary artery calcification rather than either condition alone. Finally, lower TRAIL level was independently associated with increased mortality in smokers particularly in those with comorbid emphysema and coronary artery calcification (HR = 1.38, 95% CI 1.01-1.90). CONCLUSIONS: TRAIL level is reduced in smokers with comorbid emphysema and coronary artery disease, and is associated with reduced survival.

CT-based Visual Classification of Emphysema: Association with Mortality in the COPDGene Study.

Purpose To determine whether visually assessed patterns of emphysema at CT might provide a simple assessment of mortality risk among cigarette smokers. Materials and Methods Of the first 4000 cigarette smokers consecutively enrolled between 2007 and 2011 in this COPDGene study, 3171 had data available for both visual emphysema CT scores and survival. Each CT scan was retrospectively visually scored by two analysts using the Fleischner Society classification system. Severity of emphysema was also evaluated quantitatively by using percentage lung volume occupied by low-attenuation areas (voxels with attenuation of -950 HU or less) (LAA-950). Median duration of follow-up was 7.4 years. Regression analysis for the relationship between imaging patterns and survival was based on the Cox proportional hazards model, with adjustment for age, race, sex, height, weight, pack-years of cigarette smoking, current smoking status, educational level, LAA-950, and (in a second model) forced expiratory volume in 1 second (FEV1). Results Observer agreement in visual scoring was good (weighted κ values, 0.71-0.80). There were 519 deaths in the study cohort. Compared with subjects who did not have visible emphysema, mortality was greater in those with any grade of emphysema beyond trace (adjusted hazard ratios, 1.7, 2.5, 5.0, and 4.1, respectively, for mild centrilobular emphysema, moderate centrilobular emphysema, confluent emphysema, and advanced destructive emphysema, P < .001). This increased mortality generally persisted after adjusting for LAA-950. Conclusion The visual presence and severity of emphysema is associated with significantly increased mortality risk, independent of the quantitative severity of emphysema. Online supplemental material is available for this article.

Normalized emphysema scores on low dose CT: Validation as an imaging biomarker for mortality.

The purpose of this study is to develop a computed tomography (CT) biomarker of emphysema that is robust across reconstruction settings, and evaluate its ability to predict mortality in patients at high risk for lung cancer. Data included baseline CT scans acquired between August 2002 and April 2004 from 1737 deceased subjects and 5740 surviving controls taken from the National Lung Screening Trial. Emphysema scores were computed in the original scans (origES) and after applying resampling, normalization and bullae analysis (normES). We compared the prognostic value of normES versus origES for lung cancer and all-cause mortality by computing the area under the receiver operator characteristic curve (AUC) and the net reclassification improvement (NRI) for follow-up times of 1-7 years. normES was a better predictor of mortality than origES. The 95% confidence intervals for the differences in AUC values indicated a significant difference for all-cause mortality for 2 through 6 years of follow-up, and for lung cancer mortality for 1 through 7 years of follow-up. 95% confidence intervals in NRI values showed a statistically significant improvement in classification for all-cause mortality for 2 through 7 years of follow-up, and for lung cancer mortality for 3 through 7 years of follow-up. Contrary to conventional emphysema score, our normalized emphysema score is a good predictor of all-cause and lung cancer mortality in settings where multiple CT scanners and protocols are used.

Multiorgan Failure Predicts Mortality in Emphysematous Pancreatitis: A Case Report and Systematic Analysis of the Literature.

Emphysematous pancreatitis (EP) is a subtype of acute necrotizing pancreatitis (ANP) characterized by the presence of gas in and around the pancreas. Although investigators have studied prognostic factors in ANP, less is known about EP. We aimed to determine predictors of mortality and identify changes in management strategies for EP. A PubMed search was performed to identify EP cases. Data were gathered about patient demographics, clinical findings, laboratory results, radiological studies, procedures, outcomes, and mortality. Data were analyzed using univariate and multivariate logistic regression analyses. Including a case from our institution, the study cohort included 64 subjects. The overall mortality rate was 32.8% (21/64). On univariate analysis, age (P = 0.019), hypotension (P = 0.007), gas outside the pancreas on computed tomography imaging (P = 0.003), initial surgical evacuation (P = 0.007), and the development of multiorgan failure (P = 0.008) were associated with mortality. On multivariate analysis, only the development of multiorgan failure was found to be an independent predictor of mortality (P = 0.039). The overall mortality rate of 32.8% for EP is similar to the mortality rates published for ANP. The development of multiorgan failure in EP is strongly associated with increased mortality. Percutaneous and endoscopic approaches have been replacing surgical interventions.

Predicting Structure-Function Relations and Survival following Surgical and Bronchoscopic Lung Volume Reduction Treatment of Emphysema.

Lung volume reduction surgery (LVRS) and bronchoscopic lung volume reduction (bLVR) are palliative treatments aimed at reducing hyperinflation in advanced emphysema. Previous work has evaluated functional improvements and survival advantage for these techniques, although their effects on the micromechanical environment in the lung have yet to be determined. Here, we introduce a computational model to simulate a force-based destruction of elastic networks representing emphysema progression, which we use to track the response to lung volume reduction via LVRS and bLVR. We find that (1) LVRS efficacy can be predicted based on pre-surgical network structure; (2) macroscopic functional improvements following bLVR are related to microscopic changes in mechanical force heterogeneity; and (3) both techniques improve aspects of survival and quality of life influenced by lung compliance, albeit while accelerating disease progression. Our model predictions yield unique insights into the microscopic origins underlying emphysema progression before and after lung volume reduction.

The predictors of mortality and secular changes in management strategies in emphysematous gastritis.

BACKGROUND AND AIMS: Emphysematous gastritis (EG) is caused by invasion of the gastric wall by gas-producing organisms and carries mortality rate up to 60%. Our investigation aimed to determine the predictors of survival and the secular trends in survival rates of subjects with EG. METHODS: PubMed search was completed to identify previous cases of EG. In addition, we included a recent case from our center. Statistical analysis was completed with two-sided Chi2 tests for categorical data and t-tests for continuous variables using SPSS v. 22.0 (SPSS Inc, Chicago, IL). RESULTS: Study cohort included 59 adults. Mean age was 55.5 years; mean LOS was 28.6 days, and 44.1% of subjects were female. Subjects who had EG before 2000 had significantly higher rates of exploratory laparotomy compared to subjects who had EG after 2000 (62.5% vs. 22.2%, P=0.002). In contrast, subjects with EG after 2000 had significantly higher rates of EGD (55.6% vs. 18.8%, P=0.003) and lower rates of mortality (33.3% vs. 59.4%, P=0.046) compared to subjects with EG on or before 2000. In multivariate logistic regression analysis, the only independent predictor of mortality was length of stay (P=0.047). CONCLUSION: We showed that previously reported 60% mortality rate of EG has been reduced to 33.3% for cases reported after 2000. EGD has been utilized more often while surgical interventions are used only in carefully selected cases. Our data suggests that early endoscopic evaluation and optimal medical management can perhaps continue to improve survival in subjects with EG.

Mustard gas exposure and mortality among retired workers at a poisonous gas factory in Japan: a 57-year follow-up cohort study.

OBJECTIVES: Mustard gas (MG) has been the most widely used chemical warfare agent in the past century. However, few but conflicting data exist on the effects of MG exposure on long-term mortality. We investigated MG-related mortality in retired workers at a poisonous gas factory. METHODS: We assessed mortality rates among 2392 male and 1226 female workers, whose vital status could be determined through 31 December 2009, at a poisonous gas factory operating from 1929 to 1945 in Okuno-jima, Japan. The analysis employed standardised mortality ratios (SMRs) calculated using national and prefectural references and a Cox proportional hazard regression model. Applying the Kaplan-Meier method, we compared cumulative death rates in the study cohort stratified by an 'Okuno-jima MG Index' which represented the product of HRs derived for job category and length of service. RESULTS: Among male workers, we found significant excesses in mortality from upper respiratory tract cancer (SMR 3.06), liver cancer (1.67), lung cancer (2.01) and chronic bronchitis/emphysema (4.84) compared with the national population, as well as stomach cancer (1.20) versus the Hiroshima Prefecture population. When stratified into 3 subgroups by the Okuno-jima MG Index, those with a higher Okuno-jima MG Index had significantly higher cumulative rates of death from respiratory cancer and chronic bronchitis/emphysema. CONCLUSIONS: MG exposure significantly increases the long-term risk of death from respiratory cancer and chronic bronchitis/emphysema. The Okuno-jima MG Index may be a useful indicator for estimating cumulative MG exposure.

Emphysema is an independent risk factor for 5-year mortality in patients with bronchiectasis.

INTRODUCTION: Bronchiectasis is a common disabling respiratory disease in China. However, the literatures that focused on the long-term prognosis and the risk factors for mortality are limited. OBJECTIVE: The aim of this study was to identify risk factors for 5-year mortality in patients with bronchiectasis. METHODS: A retrospective study was conducted. Patients who were newly diagnosed with bronchiectasis by thoracic conventional CT scans from January 2003 to March 2008 were assessed. Baseline characteristics, symptoms, radiographic extent, pulmonary function tests data and comorbidities were recorded through chart review. The vital status of the patients was obtained by telephone contact and record of hospital admission. Multivariate cox regression analysis was used to determine the independent risk factors for 5-year mortality. RESULTS: Eighty-nine patients newly diagnosed with bronchiectasis were included in our cohort. The mean age of the cohort was 55.29 ± 16.15 and 49.4% of the patients were female. At the end of the study, 12 patients (13.5%) died and the mean survival time was 57.05 ± 1.09 months. Multivariate analysis revealed that long-term mortality was significantly associated with emphysema (HR, 5.62; 95% confidence interval [CI], 1.35-23.46; P = 0.02) and radiographic extent (HR, 1.62; 95% CI, 1.02-2.58; P = 0.04). CONCLUSION: The main finding of our study was that emphysema might be a risk factor for mortality in patients with bronchiectasis.

[Results of conservative management of emphysematous pyelonephritis]. / Résultats du traitement conservateur de la pyélonéphrite emphysémateuse.

INTRODUCTION: Emphysematous pyelonephritis (EPN) is a rare and severe, necrotizing infection of the kidney. Diagnosis should be precocious based on computed tomography (CT). Its management remains controversial and its treatment is currently increasingly conservative. The aim of this paper is to discuss the conservative treatment of this disease through our experience in 21 patients. MATERIAL AND METHODS: A retrospective analysis including 21 patients managed conservatively for an emphysematous pyelonephritis in our department from January 2010 to April 2015. Follow-up ranged from three to 24 months. RESULTS: Of the 24 patients, seven belonged to class 1, twelve to class 2 and two to class 4. Obstruction of the upper urinary tract was found in 16 cases. On the risk factor stratification, thrombocytopenia was found in five cases, renal function impairment in 10 cases and a septic shock in four cases. All the patients were initially managed with aggressive fluid and electrolyte resuscitation, control of blood sugar levels, and broad-spectrum antibiotics. Drainage of the urinary tract was performed by double-J stent in 14 patients and with ureteral catheter in six patients. One patient had urinary distension secondary to a urethral stricture with bilateral emphysematous pyelitis. In this case, drainage consisted in suprapubic bladder catheter only. The outcome was favorable in 18 patients and the control CT showed a decline or complete disappearance of gas in urinary tract and/or renal parenchyma after an average period of 12 days. A secondary nephrectomy was performed in two cases. Specific mortality rate was zero. CONCLUSION: PNE remains a severe infection involving the vital prognosis. Computed tomography makes an early diagnosis. Treatment should be conservative based on the association of medical intensive care and drainage, percutaneous or endoscopic, urgently. Nephrectomy should be reserved for extensive forms with multiple organ dysfunction or failure of conservative treatment.

[Prognostic factors of morbimortality in patients with emphysematous pyelonephritis]. / Factores pronósticos de morbimortalidad en pacientes con pielonefritis enfisematosa.

BACKGROUND: Emphysematous pyelonephritis (EPN) is a severe infection of the urinary tract, caused by gas accumulation within the collecting system, the renal parenchyma, and/or the perirenal tissue. The cause of this infection is not known at all; however, it has been suggested that it is produced by the glucose fermentation provoked by enterobacteriaceae or anaerobic organisms. Our objective was to evaluate the predictors of morbidity and mortality in patients diagnosed with EPN. METHODS: It was carried out a historical cohort study of patients diagnosed with EPN in our hospital from March 2005 to December 2014. Patients with adverse outcome were identified. We defined adverse outcome as patients requiring stay in intensive care unit, who presented nephrectomy and/or who died. A multiple regression analysis was conducted to establish the relation of each clinical factor with the adverse outcome. RESULTS: 73 records were included for analysis, 48 were women (65.8 %) and 25 men. Diabetes, urolithiasis, E. coli infection and septic shock occurred in 68.5, 68.5, 63, and 15.1 %, respectively. We found that leukocytosis ≥12 000 µl (OR 43.65, 95 % CI 2.36-805, p <0.001), thrombocytopenia ≤120 000 µl (OR 363, 95 % 9.2-14208, p <0.0001), and Huang's radiological class 3 (OR 62, 95 % CI 4-964, p < 0.001) were factors significantly associated with adverse outcome. CONCLUSION: Thrombocytopenia, leukocytosis and Huang's radiological class 3 are associated with adverse outcome in patients with EPN.

Introducción: La pielonefritis enfisematosa es una infección grave del tracto urinario caracterizada por la presencia de gas en los sistemas colectores, en el parénquima renal o en el tejido perirrenal; su causa no es del todo conocida, pero se ha sugerido que se debe a la fermentación de glucosa por enterobacterias y anaerobios. El objetivo fue evaluar los factores pronósticos de morbimortalidad en pacientes con diagnóstico de pielonefritis enfisematosa. Métodos: estudio de cohorte histórica en pacientes con diagnóstico de pielonefritis enfisematosa que ingresaron a nuestro hospital de marzo de 2005 a diciembre de 2014. Se identificaron los pacientes con desenlace adverso definido como aquel que requirió estancia en unidad de cuidados intensivos, nefrectomía o muerte. Se realizó una regresión logística múltiple para obtener la relación de cada factor pronóstico con el desenlace adverso. Resultados: Fueron evaluados 73 pacientes (48 mujeres [65.8 %]). Diabetes, litiasis urinaria, infección por Escherichia coli y el estado de choque se presentaron en 68.5 %, 68.5 %, 63 % y 15.1 %, respectivamente. Fueron factores significativos para desenlace adverso la leucocitosis ≥ 12 000 µL (RM 43.65, IC 95 % 2.36-805, p < 0.001), la trombocitopenia ≤ 120 000 µL (RM 363, IC 95 % 9.2-14208, p < 0.0001), y la clase radiológica 3 de Huang (RM 62, IC 95 % 4-964, p < 0.001). Conclusión: la trombocitopenia, la leucocitosis y la clase radiológica 3 se asociaron con un desenlace adverso en los pacientes con pielonefritis enfisematosa.

Circulating desmosine levels do not predict emphysema progression but are associated with cardiovascular risk and mortality in COPD.

Elastin degradation is a key feature of emphysema and may have a role in the pathogenesis of atherosclerosis associated with chronic obstructive pulmonary disease (COPD). Circulating desmosine is a specific biomarker of elastin degradation. We investigated the association between plasma desmosine (pDES) and emphysema severity/progression, coronary artery calcium score (CACS) and mortality.pDES was measured in 1177 COPD patients and 110 healthy control subjects from two independent cohorts. Emphysema was assessed on chest computed tomography scans. Aortic arterial stiffness was measured as the aortic-femoral pulse wave velocity.pDES was elevated in patients with cardiovascular disease (p<0.005) and correlated with age (rho=0.39, p<0.0005), CACS (rho=0.19, p<0.0005) modified Medical Research Council dyspnoea score (rho=0.15, p<0.0005), 6-min walking distance (rho=-0.17, p<0.0005) and body mass index, airflow obstruction, dyspnoea, exercise capacity index (rho=0.10, p<0.01), but not with emphysema, emphysema progression or forced expiratory volume in 1 s decline. pDES predicted all-cause mortality independently of several confounding factors (p<0.005). In an independent cohort of 186 patients with COPD and 110 control subjects, pDES levels were higher in COPD patients with cardiovascular disease and correlated with arterial stiffness (p<0.05).In COPD, excess elastin degradation relates to cardiovascular comorbidities, atherosclerosis, arterial stiffness, systemic inflammation and mortality, but not to emphysema or emphysema progression. pDES is a good biomarker of cardiovascular risk and mortality in COPD.

Influenza A virus-dependent remodeling of pulmonary clock function in a mouse model of COPD.

Daily oscillations of pulmonary function depend on the rhythmic activity of the circadian timing system. Environmental tobacco/cigarette smoke (CS) disrupts circadian clock leading to enhanced inflammatory responses. Infection with influenza A virus (IAV) increases hospitalization rates and death in susceptible individuals, including patients with Chronic Obstructive Pulmonary Disease (COPD). We hypothesized that molecular clock disruption is enhanced by IAV infection, altering cellular and lung function, leading to severity in airway disease phenotypes. C57BL/6J mice exposed to chronic CS, BMAL1 knockout (KO) mice and wild-type littermates were infected with IAV. Following infection, we measured diurnal rhythms of clock gene expression in the lung, locomotor activity, pulmonary function, inflammatory, pro-fibrotic and emphysematous responses. Chronic CS exposure combined with IAV infection altered the timing of clock gene expression and reduced locomotor activity in parallel with increased lung inflammation, disrupted rhythms of pulmonary function, and emphysema. BMAL1 KO mice infected with IAV showed pronounced detriments in behavior and survival, and increased lung inflammatory and pro-fibrotic responses. This suggests that remodeling of lung clock function following IAV infection alters clock-dependent gene expression and normal rhythms of lung function, enhanced emphysematous and injurious responses. This may have implications for the pathobiology of respiratory virus-induced airway disease severity and exacerbations.