Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis.

AIMS: Patients with acute pulmonary embolism (PE) at low risk for short-term death are candidates for home treatment or short-hospital stay. We aimed at determining whether the assessment of right ventricle dysfunction (RVD) or elevated troponin improves identification of low-risk patients over clinical models alone. METHODS AND RESULTS: Individual patient data meta-analysis of studies assessing the relationship between RVD or elevated troponin and short-term mortality in patients with acute PE at low risk for death based on clinical models (Pulmonary Embolism Severity Index, simplified Pulmonary Embolism Severity Index or Hestia). The primary study outcome was short-term death defined as death occurring in hospital or within 30 days. Individual data of 5010 low-risk patients from 18 studies were pooled. Short-term mortality was 0.7% [95% confidence interval (CI) 0.4-1.3]. RVD at echocardiography, computed tomography or B-type natriuretic peptide (BNP)/N-terminal pro BNP (NT-proBNP) was associated with increased risk for short-term death (1.5 vs. 0.3%; OR 4.81, 95% CI 1.98-11.68), death within 3 months (1.6 vs. 0.4%; OR 4.03, 95% CI 2.01-8.08), and PE-related death (1.1 vs. 0.04%; OR 22.9, 95% CI 2.89-181). Elevated troponin was associated with short-term death (OR 2.78, 95% CI 1.06-7.26) and death within 3 months (OR 3.68, 95% CI 1.75-7.74). CONCLUSION: RVD assessed by echocardiography, computed tomography, or elevated BNP/NT-proBNP levels and increased troponin are associated with short-term death in patients with acute PE at low risk based on clinical models. RVD assessment, mainly by BNP/NT-proBNP or echocardiography, should be considered to improve identification of low-risk patients that may be candidates for outpatient management or short hospital stay.

[The cost of pulmonary thromboembolism treatment]. / Pulmoner tromboemboli tedavisinde maliyet.

INTRODUCTION: Primary aim of this study is to determine the financial burden of Vitamin K Antagonists (VKA), low molecular weight heparins (LMWH) and new oral anticoagulants (NOAC) which are used in the treatment of the pulmonary thromboembolism (PTE). Secondary aim is to show long term complications of the treatment options. MATERIALS AND METHODS: The patients who are diagnosed with PTE between May 2016 and March 2018 at Faculty of Medicine Karadeniz Technical University Hospital were observed prospectively. Hospitalization costs were calculated on patients who were treated only for PTE by hospitalized in the Chest Diseases Service in the acute period. Maintenance costs were calculated over all patients who regulary admitted to our outpatient clinic with the diagnosis of PTE. Data were presented as mean ± SD and median ± interquartilee range. A p-value of <0.05 was accepted to be significant. RESULT: Fifty five (37.2%) of the patients were male, 93 (62.8%) were female and the median age was 68 (range 18-95). The median hospitalization time and cost of patients who are discharged with VKA (n: 22) compared with patients discharged with LMWH (n: 22) was found to be increased (1316.82 TL 7,5 days / 803.36 TL, 5 days p<0.001). Statistical analysis could not be performed with NOAC (n: 2). In the analysis of sixth month costs, LMWH cost was found to be higher than VKA cost (6.927.15 ± 2.687.67 TL/698.29 ± 483.51 TL p<0.001). However VKA treatment tended to be less expensive than treatment with NOACs (698.29 ± 483.51 TL/1.050.81 ± 300.28 TL p= 0.140). CONCLUSIONS: In the acute period of PTE, VKA increases the length of hospitalization and hospital costs in patients treated at the hospital. In the maintenance period, VKA tends to have a lower cost compared to NOACs.

[Lupus-like syndrome in patients treated with anti-TNF-α factors]. / Anti-TNF tedavi ile iliskili lupus like sendromu.

A 56-year-old male patient presented with history of complaints of night sweats, short ness of breath, cough and yellow sputum, fever. There was a history of tumor neurosis factor-alpha (etanercept) due to ankylosing spondylitis. Postero-anterior chest X-ray; the right sinus was blunt, the right diaphragm had linear opacity compatible with atelectasis extending from the diaphragm to the periphery, left pleural effusion, left middle basal paracardiac opacity. In thorax tomography; pleural effusion and pericardial effusion and compressive atelectasis in the adjacent lung parenchyma were detected. Lymphocyte dominance had in cytological examination. Active chronic pleuritis and fibrinous exudate as benign cytology were reported in pleural biopsy. We are thought to develop pleurisy due to anti TNF-induced lupus like syndrome. 100 mg prednol was applied for three days. One month later the control was found toregress in the filter.

[Causes of mediastinal/hilar granulomatous lymphadenitis]. / Mediastinal/hiler granülomatöz lenfadenit etyolojisi.

INTRODUCTION: Granulomatous lung disease (GLD) is caused by a wide range of conditions and it is challenge for pulmonologist. A detailed history of exposures is fundamental in GDL and has been found pivotal to reach a precise diagnosis. MATERIALS AND METHODS: Between September 2014 and December 2016, the distribution of patients diagnosed with granulomatous lymphadenitis in the mediastinal/hilar lymph nodes by endobronchial ultrasound (EBUS) or mediastinoscopy was analyzed. To be listed as 'confident', a diagnosis of sarcoidosis required compatible histological, radiological and clinical findings in conjunction with negative cultures. Infectious entities listed as 'confident' had either microorganisms in tissue section, positive culture, positive serology or positive antigen detection in a consistent clinical pathological setting. RESULT: Granulomatous lymphadenitis was detected in 110 patients. The included 110 cases consisted of 70.9% women and median age of 53 (range 44-61) years. The final diagnosis of the patients was accepted to be sarcoidosis in 79 (71.8%), sarcoid like granulomas in 7 (6.4%), tuberculosis in 4 (3.6%), silicosis in 4 (3.6%), drug-associated granuloma in 2 (1.8%), hypersensitivity pneumonitis in 1 (0.9%), Chron disease in 1 (0.9%), unspecified in 12 (10.9%). Three patients were classified as tuberculosis based on culture. CONCLUSIONS: In this study, we found that the most common cause of granulomatous lymphadenitis was sarcoidosis. Contrary to expectations, the number of patients diagnosed with tuberculosis was very low.

Classification of high-risk with cardiac troponin and shock index in normotensive patients with pulmonary embolism.

Accurate risk stratification of normotensive patients with acute pulmonary embolism (PE) require further investigation. We aimed to develop a simple model using clinical (shock index) and laboratory findings (cardiac Troponin, echocardiography) to assess the risk of 30-day mortality in normotensive patients with acute PE. In this retrospective study, 489 normotensive patients with acute PE diagnosed objectively. The primary end-point was defined as a all cause 30-day mortality. Shock index was calculated on admission. The primary end-point occurred in 67 (13.7%, 95% CI 10.7-16.8) patients with acute PE. Predictors of complications included elevated cardiac troponin (OR 1.7, 95% CI 1.3-2.2) and shock index (OR 1.3, 95% CI 1.1-1.5) by multivariable analysis. Risk index point was created based on OR. The model identified stages (stage I: 0-1 point, stage II: 2 points and stage III: 3 point) with 30-day mortality rates of 4.3, 19 and 38.6 %, respectively. The shock index and cardiac troponin can be safely used in combination to determine intermediate risk in patients with PE in emergency departmant. The study provided observations that will require prospective validation before the proposed risk score is adopted in clinical practice.

[A rare case: Kikuchi-Fujimoto disease]. / Nadir görülen bir olgu: Kikuchi-Fujimoto hastaligi.

Kikuchi-Fujimoto's disease (CFD) is a disease that usually exhibits self-limited benign lymph node involvement. Etiology of illness is not fully understood.Differential diagnosis should be performed well because lymph node involvement can be confused with lymphoma type diseases. A 35-year-old male patient with weakness, joint aches, fever, loss of appetite, weight loss, night sweating symptoms presented with the literature.

The Significance of the Relative Lymphocyte Count as an Independent Predictor of Cardiovascular Disease in Patients with Obstructive Sleep Apnea Syndrome.

OBJECTIVE: The aim of this study was to determine whether or not relative lymphocyte count (RLC) is associated with cardiovascular disease (CVD) in patients with obstructive sleep apnea syndrome (OSAS). SUBJECTS AND METHODS: In this study, 141 patients diagnosed with OSAS using polysomnography were enrolled. Patients were classified according to the severity of OSAS as determined by the apnea-hypopnea index (AHI) and presence of CVD. Lymphocyte count and other hematological parameters at complete blood count were determined and compared between patients with and without CVD. Multivariate regression analysis was used to estimate the associated factors for presence of CVD. RESULTS: Absolute and relative lymphocyte counts were lower in the OSAS patients with CVD compared to those without CVD (mean absolute lymphocyte counts: 2.0 × 103 vs. 2.5 × 103 µl, p = 0.004, and mean RLC: 28.3 vs. 33.9%, p = 0.001, respectively). OSAS patients with CVD (14.2) had higher red cell distribution width values than the patients without CVD (13.4) (p = 0.005). Multivariate analysis identified RLC as an independent predictor of CVD in patients with OSAS (odds ratio = 0.9, 95% CI: 0.85-1.0, p = 0.042). CONCLUSION: RLC was identified as an independent predictor of CVD in patients with OSAS. Since RLC is a widely available diagnostic tool with no additional costs over the routinely performed complete blood count, it can be used for predicting CVD in patients with OSAS.

[Inflammatory bowel disease and pulmonary embolism: Because of 3 cases]. / Inflamatuvar bagirsak hastaligi ve pulmoner emboli: 3 olgu nedeniyle.

Thromboembolic complications are an important cause of morbidity and mortality in inflammatory bowel diseases (IBD). Thromboembolic events are observed more frequently during acute flare of the disease, especially patients received steroid therapy. Increase in awareness and especially anticoagulation prophylaxis in these patients are extremely important. In this article, three cases with diagnosed pulmonary thromboembolism (PE) were presented accompanied by the current literature.

Value of Cardiac Troponin and sPESI in Treatment of Pulmonary Thromboembolism at Outpatient Setting.

BACKGROUND: Currently, guidelines do not recommend any standard approach for treatment of pulmonary thromboembolism (PTE) at outpatient setting. We investigated the efficacy and safety of a 90-day anticoagulant treatment of outpatients diagnosed with PTE who had negative troponin levels and low-risk simplified pulmonary embolism severity index (sPESI) at presentation. METHODS: This prospective cohort study included a total of 206 patients with objectively confirmed acute symptomatic PTE. Any troponin negative (cTn-) and low sPESI patients (as classified Group-1) were treated in outpatient setting. The primary endpoint was all-cause mortality during the first 90 days, and the secondary endpoint included non-fatal symptomatic recurrent PTE or non-fatal major bleeding. Presence of cancer was excluded from sPESI score. RESULTS: Fifty-two of 206 patients were eligible for had Group-1, and 31 were treated at outpatients settings. The 90-day all-cause mortality rate was 3.2 % among patients who received outpatient treatment. Otherwise cTn+ and high-risk sPESI 90-day mortality rate was 43.7 %. No difference was found in terms of secondary endpoints between the patients who received outpatient treatment and those who received inpatient treatment in Group-1 (p = NS). In our study, cancer was present in 16 (51.6 %) of the 31 outpatients. CONCLUSION: We observed that patients with acute PTE, low-risk sPESI, and negative troponin levels can be safely treated in the outpatient settings. Also the presence of cancer alone does not necessitate hospitalization.

[Treatment and diagnosis of pulmonary embolism in pregnancy]. / Gebelerde pulmoner tromboembolinin tani ve tedavisi.

When occurring during pregnancy, venous thrombo-embolism is a major cause of maternal mortality. The risk is highest in the third trimester of pregnancy and over the 6 weeks of the postpartum period. Exposure of the foetus to ionizing radiation is a concern when investigating suspected PE during pregnancy; although this concern is largely overruled by the hazards of missing a potentially fatal diagnosis. This is particularly true for pregnant patients with suspected high risk. A normal D-dimer value has the same exclusion value for PE in pregnant women as for other patients with suspected PE but is found more rarely, because plasma D-dimer levels physiologically increase throughout pregnancy. In pregnant women with suspected PE and signs and symptoms of DVT, guidelines suggest performing bilateral compression ultrasound of lower extremities. Use of lung scintigraphy as the preferred test in the setting of a normal CXR. The treatment of PE in pregnancy is based on heparin anticoagulation. Increasing experience suggests that LMWHs are safe in pregnancy, and their use is endorsed in several reports. Treatment should consist of a weight-adjusted dose of LMWH.

[A newly-defined entity: combined pulmonary fibrosis and emphysema syndrome]. / Yeni tanimlanan bir antite: Kombine pulmoner fibrozis ve amfizem sendromu.

Combined pulmonary fibrosis and emphysema (CPFE) syndrome is a rare disease characterized with shortness of breath, upper lobe emphysema, lower lobe fibrosis and impairment of gas exchange. This syndrome is a disease usually seen in male smokers. Pulmonary hypertension is associated with mortality. Another important feature, spirometric volumes relatively protected and a reduction in carbon monoxide diffusion test. CPFE syndrome in the literature so far have been identified in only 70 patients. In this review CPFE syndrome is presented with literature.

Red cell distribution width: a new predictor for chronic thromboembolic pulmonary hypertension after pulmonary embolism.

The most important long-term complication of pulmonary thromboembolism is chronic thromboembolic pulmonary hypertension (CTEPH) that is associated with considerable morbidity and mortality. It is uncertain why some patients with acute pulmonary embolism (PE) develop CTEPH and others do not. Elevated red cell distribution width (RDW) has been associated with adverse outcomes of heart failure, PE, and idiopathic pulmonary hypertension. The aim of the present study was to investigate whether RDW might be a predictor of CTEPH in PE patients or not. This study is a retrospective cohort study. A total of 203 consecutive patients with acute PE were included. The RDW was higher in the CTEPH patients than the patients without CTEPH (17.04 ± 3.46, 14.64 ± 1.82, respectively, p = 0.015). RDW was also higher in the CTEPH patients at the time of diagnosis of CTEPH during follow-up compared with the baseline RDW level at the time of PE diagnosis (18.63 ± 3.58, 17.02 ± 3.59, respectively, p = 0.014). The optimal cutoff value of the RDW for predicting CTEPH was 14.65. The area under the curve of RDW for the prediction of CTEPH was 0.735 (95% confidence interval (CI): 0.600-0.869); in cases with RDW levels >14.65%, the specificity, sensitivity, and negative predictive value for CTEPH were 62% (95% CI: 0.55-0.69), 75% (95% CI: 0.47-0.92), and 96.7% (95% CI: 0.91-0.99), respectively. A multivariate regression analysis showed that RDW, hazard ratio: 1.58 (95% CI: 1.09-2.30), was a predictor of CTEPH (p = 0.016). High level of RDW was an independent predictor of CTEPH in PE patients. Therefore, RDW levels may provide a prediction for CTEPH in PE patients.

Pentraxin-3: A novel biomarker for discriminating parapneumonic from other exudative effusions.

BACKGROUND AND OBJECTIVE: Pentraxin-3 (PTX-3) is a relatively new marker of inflammation that has not been previously tested in pleural effusions. We aimed to assess whether PTX-3 is an accurate biomarker of parapneumonic effusions (PPE) and whether it discriminates complicated (CPPE)from non-complicated PPE. METHODS: The concentrations of pleural fluid PTX-3 were measured by a commercial enzyme-linked immunosorbent assay in a prospective cohort of 84 patients with pleural effusions, including 24 PPE, 40 malignant, and 20 miscellaneous exudative effusions. The area under the curve quantified the overall diagnostic accuracy of the test. A multivariate logistic regression analysis selected pleural fluid biochemistries predictive of PPE. RESULTS: Median pleural fluid PTX-3 levels were higher in PPE than in both malignant effusions and other exudates (32.4 ng/mL vs 6.7 ng/mL, and 8.5 ng/mL, respectively, P < 0.001). PTX-3 > 12 ng/mL yielded 88% sensitivity, 73% specificity, likelihood ratio positive 3.3 and likelihood ratio negative 0.17 for diagnosing PPE, with an area under the curve of 0.855 (95% CI: 0.769-0.941). In the multivariate analysis, pleural PTX-3 levels remained associated with increased diagnostic odds for PPE (odds ratio 17.7, 95% confidence interval: 3.7-85.1, P < 0.001). There was a non-significant trend towards higher pleural PTX-3 levels in CPPE as compared with non-complicated. CONCLUSIONS: High concentrations of PTX-3 in pleural effusions are very sensitive to differentiate PPE from non-PPE. However, they do not seem to differentiate uncomplicated-complicated from CPPE differentiation.

Red cell distribution width in patients with obstructive sleep apnea syndrome.

BACKGROUND: Red cell distribution width (RDW) has been shown to be associated with adverse outcomes in left-sided heart failure, pulmonary hypertension, and in patients in the ICU. However, the role of RDW is unknown in patients with obstructive sleep apnea syndrome (OSAS), especially in OSAS patients with cardiovascular diseases. METHODS: One hundred thirty-seven patients were investigated by polysomnography (PSG) for OSAS. The patients were classified as a control group or as the OSAS group according to the apnea-hypopnea index (AHI). The RDW, hemoglobin level, and mean corpuscular volume (MCV) were determined. C-reactive protein (CRP) levels were measured. RESULTS: The RDW values were higher in the OSAS group than in the controls [13.6% (12-23%) vs. 12.9% (11.7-14.5%), p=0.003]. The RDW values were higher in patients with cardiovascular diseases [13.7% (11.7-23.2%) vs. 13.2% (12-16.9%), p=0.001]. RDW ≥ 13.6% (odds ratio [OR] =1.5 [95% CI = 1.0-2.0], p = 0.014) was found to be associated with increased risk for cardiovascular disease in patients with OSAS on multivariate analysis. It was also shown that there was a significant correlation between the RDW and the AHI (r=0.272), age (r=0.362), mean SaO(2) (r=0.375), systolic pulmonary artery pressure (r=0.435), and CRP level (r=0.275) in study population. CONCLUSIONS: RDW is a newly recognized and widely available diagnostic tool with no additional cost over the routinely performed hemogram. RDW is independently associated with cardiovascular disease in patients with OSAS in our cross-sectional study.

[Prognostic role of biomarkers and right ventricular dysfunction in pulmonary embolism]. / Pulmoner embolide biyobelirteçlerin ve sag ventrikül disfonksiyonun prognostik rolü

Pulmonary embolism is morbidity and mortality remain high. The short-term prognosis of pulmonary embolism depends on haemodynamic status and underlying disease massive pulmonary embolism, defined as pulmonary embolism that is associated with systemic hypotension which increases up to 50% in hospital mortality. However, the in-hospital mortality of patients with normal blood pressure pulmonary embolism has been reported to vary from 3 to 15%. Right ventricular dysfunction showed by echocardiography or computerized tomography and elevated cardiac enzymes have been used to determine mortality in these patients with pulmonary embolism. In this article; we reviewed the prognostic value of right ventricular dysfunction as evaluated by echocardiography or spiral computerized tomography, and the prognostic value of increased levels of cardiac markers in patients with pulmonary embolism.

The role of risk factors in delayed diagnosis of pulmonary embolism.

BACKGROUND: Despite diagnostic advances, delays in the diagnosis of pulmonary embolism (PE) are common. OBJECTIVE: In this study, we aimed to investigate the relationship between delays in the diagnosis of PE and underlying risk factors for PE. METHODS: We retrospectively evaluated the records of 408 patients with acute PE. Patients were divided into 2 groups, surgical or medical, based on risk factors leading to the embolism. Analysis involved demographic characteristics of the patients, dates of symptom onset, first medical evaluation, and confirmatory diagnostic tests. Diagnostic delay was described as diagnosis of PE more than 1 week after symptom onset. RESULTS: The mean time to diagnosis for all patients was 6.95 ± 8.5 days (median, 3 days; range, 0-45 days). Of the total number of patients, 29.6% had presented within the first 24 hours and 72.3% within the first week. The mean time to diagnosis was 4.4 ± 7.6 days (median, 2 days; range, 0-45 days) in the surgical group and 8.0 ± 8.6 days (median, 4 days; range, 0-45 days) in the medical group (P = .000). The mean time to diagnosis in the medical group was approximately 4 times greater than that of the surgical group on univariate analysis. Early or delayed diagnosis had no significant impact on mortality in either group. CONCLUSION: Delay in the diagnosis of PE is an important issue, particularly in medical patients. We suggest that a public health and educational initiative is needed to improve efficiency in PE diagnosis.

C-reactive protein alone or combined with cardiac troponin T for risk stratification of respiratory intensive care unit patients.

BACKGROUND: Mortality is high among patients admitted to intensive care units (ICUs). Several prognostic markers have been described in such patients, but the literature contains no data comparing C-reactive protein (CRP) and cardiac troponin T (cTn-T), nor of a combination of CRP and cTn-T in the same patient group in the ICU. METHODS: This was a retrospective electronic data review of patients who presented to the emergency department for respiratory reasons between December 2007 and December 2009 and in whom CRP and cTn-T levels were measured. Patients with a diagnosis of pulmonary embolism and acute coronary syndrome were excluded. We recorded demographics, chronic diseases, admission diagnosis, Simplified Acute Physiology Score II (SAPS II), ICU stay, and CRP and cTn-T concentrations. RESULTS: We included the records of 158 patients. Mean ICU stay was 9.9 days (range 1-65 d), and mean hospital stay was 14.1 days (range 1-72 d). For predicting mortality, receiver operating characteristic analysis gave a CRP cutoff value of ≥ 10 mg/dL, and a CTn-T cutoff value of ≥ 0.01 ng/mL. For CRP the mortality area under the curve was 0.691 (95% CI 0.608-0.775), the sensitivity was 65%, and the specificity was 70%. For cTn-T the mortality area under the curve was 0.733 (95% CI 0.655-0.812), the sensitivity was 78%, and the specificity was 56%. Of the patients who died, 65% had CRP ≥ 10 mg/dL and 78% had cTn-T ≥ 0.01 ng/mL. On multivariable regression analysis, CRP ≥ 10 mg/dL was associated with 6.6-fold higher (95% CI 1.7-21.3) ICU mortality. There was no advantage for models that combined CRP and cTn-T. CRP alone was more valuable in predicting ICU mortality than in combination with troponin or SAPS II. CONCLUSIONS: Elevated CRP is an independent early prognostic marker of mortality risk in ICU patients. We suspect that a CRP-based prognosis strategy may be useful.

[Fondaparinux treatment in heparin induced thrombocytopenia:a case report]. / Heparine bagli trombositopeninin tedavisinde fondaparinuks: Bir olgu sunumu.

Heparin induced thrombocytopenia is a serious complication of heparin therapy that has a high levels of morbidity and mortality due to thrombotic complications. Heparin induced thrombocytopenia usually develops between days 5 and 14 (inclusive) following initiation of heparin. When heparin induced thrombocytopenia is suspected, heparin should be discontinued and treatment with a direct thrombin inhibitor should be initiated. Heparin induced thrombocytopenia occurs more frequently with unfractionated heparin than with low molecular weight heparin. In this manuscript, we presented a case diagnosis with heparin induced thrombocytopenia who was given low molecular weight heparin for prophylaxis. We tried to make an overview of new treatment choices along with current literature.

A review of venous thromboembolism in COVID-19: A clinical perspective.

Coronavirus disease-19 (COVID-19) started in Wuhan, China in December 2019 and spread to all around the world in a short period of time. Hospitalized patients with COVID-19 mostly could suffer from an abnormal coagulation activation risk with increased venous thrombosis events and a poor clinical course. The reported incidence rates of thrombotic complications in hospitalized COVID-19 patients vary between 2.6 and 85% (both in non-critically ill and critically ill patients). The risk of venous thromboembolism is not known in non-hospitalized patients with COVID-19. There are numerous studies and guidelines for administration of thromboprophylaxis for COVID-19 cases. All hospitalized COVID-19 patients should take pharmacological thromboprophylaxis if there is no contraindication. However, there is no consensus on this issue. In this review, we discussed all these approaches in a critical perspective.