Predictors of outcome of noninvasive ventilation in severe COPD exacerbation.

BACKGROUND: Noninvasive ventilation (NIV) reduces the rate of endotracheal intubation (ETI) and overall mortality in severe acute exacerbation of COPD (AECOPD) with acute respiratory failure and is increasingly applied in respiratory intermediate care units. However, inadequate patient selection and incorrect management of NIV increase mortality. We aimed to identify factors that predict the outcome of NIV in AECOPD. Also, we looked for factors that influence ventilator settings and duration. METHODS: A prospective cohort study was undertaken in a respiratory intermediate care unit in an academic medical center between 2016 and 2017. Age, BMI, lung function, arterial pH and pCO2 at admission (t0), at 1-2 h (t1) and 4-6 h (t2) after admission, creatinine clearance, echocardiographic data (that defined left heart dysfunction), mean inspiratory pressure during the first 72 h (mIPAP-72 h) and hours of NIV during the first 72 h (dNIV-72 h) were recorded. Main outcome was NIV failure (i.e., ETI or in-hospital death). Secondary outcomes were in-hospital mortality, length of stay (LOS), duration of NIV (days), mIPAP-72 h, and dNIV-72 h. RESULTS: We included 89 patients (45 male, mean age 67.6 years) with AECOPD that required NIV. NIV failure was 12.4%, and in-hospital mortality was 11.2%. NIV failure was correlated with days of NIV, LOS, in-hospital mortality (p < 0.01), and kidney dysfunction (p < 0.05). In-hospital mortality was strongly associated with days of NIV (OR 1.27, 95%CI: 1.07-1.5, p < 0.01) and with FEV1 (p < 0.05). All other investigated parameters (including left heart dysfunction, dNIV-72 h, mIPAP-72 h, pH, etc.) did not influence NIV failure or mortality. dNIV-72 h and days of NIV were independent predictors of LOS (p < 0.01). Regarding the secondary outcomes, left heart dysfunction and pH at 1-2 h independently predicted NIV duration (dNIV-72 h, p < 0.01), while BMI and baseline pCO2 predicted NIV settings (mIPAP-72 h, p < 0.01). CONCLUSION: In-hospital mortality and NIV failure were not influenced by BMI, left heart dysfunction, age, nor by arterial blood gas values in the first 6 h of NIV. Patients with severe acidosis and left heart dysfunction required prolonged use of NIV. BMI and pCO2 levels influence the NIV settings in AECOPD regardless of lung function.

The TB Portals: an Open-Access, Web-Based Platform for Global Drug-Resistant-Tuberculosis Data Sharing and Analysis.

The TB Portals program is an international consortium of physicians, radiologists, and microbiologists from countries with a heavy burden of drug-resistant tuberculosis working with data scientists and information technology professionals. Together, we have built the TB Portals, a repository of socioeconomic/geographic, clinical, laboratory, radiological, and genomic data from patient cases of drug-resistant tuberculosis backed by shareable, physical samples. Currently, there are 1,299 total cases from five country sites (Azerbaijan, Belarus, Moldova, Georgia, and Romania), 976 (75.1%) of which are multidrug or extensively drug resistant and 38.2%, 51.9%, and 36.3% of which contain X-ray, computed tomography (CT) scan, and genomic data, respectively. The top Mycobacterium tuberculosis lineages represented among collected samples are Beijing, T1, and H3, and single nucleotide polymorphisms (SNPs) that confer resistance to isoniazid, rifampin, ofloxacin, and moxifloxacin occur the most frequently. These data and samples have promoted drug discovery efforts and research into genomics and quantitative image analysis to improve diagnostics while also serving as a valuable resource for researchers and clinical providers. The TB Portals database and associated projects are continually growing, and we invite new partners and collaborations to our initiative. The TB Portals data and their associated analytical and statistical tools are freely available at https://tbportals.niaid.nih.gov/.

Comparative analysis of Staphylococcus aureus and Escherichia coli microcalorimetric growth.

BACKGROUND: Microcalorimetric bacterial growth studies have illustrated that thermograms differ significantly with both culture media and strain. The present contribution examines the possibility of discriminating between certain bacterial strains by microcalorimetry and the qualitative and quantitative contribution of the sample volume to the observed thermograms. Growth patterns of samples of Staphylococcus aureus (ATCC 25923) and Escherichia coli (ATCC 25922) were analyzed. Certain features of the thermograms that may serve to distinguish between these bacterial strains were identified. RESULTS: The thermograms of the two bacterial strains with sample volumes ranging from 0.3 to 0.7 ml and same initial bacterial concentration were analyzed. Both strains exhibit a roughly 2-peak shape that differs by peak amplitude and position along the time scale. Seven parameters corresponding to the thermogram key points related to time and heat flow values were proposed and statistically analyzed. The most relevant parameters appear to be the time to reach a heat flow of 0.05 mW (1.67 ± 0.46 h in E. coli vs. 2.99 ± 0.53 h in S. aureus, p < 0.0001), the time to reach the first peak (3.84 ± 0.5 h vs. 5.17 ± 0.49 h, p < 0.0001) and the first peak value (0.19 ± 0.02 mW vs. 0.086 ± 0.012 mW, p < 0.0001). The statistical analysis on 4 parameters of volume-normalized heat flow thermograms showed that the time to reach a volume-normalized heat flow of 0.1 mW/ml (1.75 ± 0.37 h in E. coli vs. 2.87 ± 0.65 h in S. aureus, p < 0.005), the time to reach the first volume-normalized peak (3.78 ± 0.47 h vs. 5.12 ± 0.52 h, p < 0.0001) and the first volume-normalized peak value (0.35 ± 0.05 mW/ml vs. 0.181 ± 0.040 mW/ml, p < 0.0001) seem to be the most relevant. Peakfit® decomposition and analysis of the observed thermograms complements the statistical analysis via quantitative arguments, indicating that: (1) the first peak pertains to a faster, "dissolved oxygen" bacterial growth (where the dissolved oxygen in the initial suspension acts as a limiting factor); (2) the second peak indicates a slower "diffused oxygen" growth that involves transport of oxygen contained in the unfilled part of the microcalorimetric cell; (3) a strictly fermentative growth component may slightly contribute to the observed complex thermal signal. CONCLUSION: The investigated strains of Staphylococcus aureus and Escherichia coli display, under similar experimental conditions, distinct thermal growth patterns. The two strains can be easily differentiated using a selection of the proposed parameters. The presented Peakfit analysis of the complex thermal signal provides the necessary means for establishing the optimal growth conditions of various bacterial strains. These conditions are needed for the standardization of the isothermal microcalorimetry method in view of its further use in qualitative and quantitative estimation of bacterial growth.

Regional advisory board position statement on optimal pneumococcal vaccination in adults. Update to 2011 consensus on adult pneumococcal disease: update on optimal pneumococcal vaccination in adults.

BACKGROUND: An important development in the field of adult pneumococcal vaccination since the last Consensus Statement, published by the Expert Panel of Central and Eastern Europe and Israel (the Region) in September 2012, was the licensure of the 13-valent pneumococcal conjugate vaccine (PCV13) for adults aged 50 years and older. DISCUSSION: The Expert Panel has developed this Position Statement as an update to its previous Consensus to address the following topics which are likely to be on the agenda of national scientific societies during the ongoing updates of vaccination recommendations in the Region: the availability of a pneumococcal conjugate vaccine for adults over 50 years of age, the available clinical evidence on its use in adults, and the future place of conjugate vaccines in adult pneumococcal vaccination. The Expert Panel concluded that there is sufficient epidemiologic immunogenicity and safety evidence to use PCV 13 in adults over 50 years of age. RESULTS: The use of conjugate vaccine induces immunological memory and can overcome some limitations associated with the plain polysaccharide vaccine (PPV). It was also agreed that, if the use of PPV is considered appropriate, PCV13 should be administered first, regardless of prior pneumococcal vaccination status.

Complications During Hospitalization in Patients With SARS-CoV-2 Pneumonia in a Romanian Pulmonary Center.

Introduction The coronavirus disease (COVID-19) was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. Facing a new and unknown virus, the entire medical community made considerable efforts to find a specific treatment, develop guidelines, and even create a vaccine. Besides all the measures taken, a wide range of complications associated with the disease increased the mortality and morbidity rates, adding more difficulty to the management of the patients. Study design We performed a retrospective study, including the patients with SARS-CoV-2 pneumonia who were admitted to our hospital between March 2020 and August 2021. We analyzed complications that developed during the hospitalization, such as respiratory failure or acute injury to other organs (the heart, pancreas, kidneys, and liver), and whether they were treatment- and hospitalization-related. Results One thousand eight hundred and forty-four cases were evaluated, and we analyzed the complications that developed during the hospitalization. Out of this, 1392 (75.48%) cases developed at least one complication during hospitalization, most frequently respiratory failure (71.14%), hyperglycemia (43.54%), renal injury (42.67%), or cardiovascular events (7.10%). Conclusion SARS-CoV-2 infection in hospitalized patients with pneumonia can cause injuries to any organ, making the management of those patients even more difficult.

Pathological Presence of Free Air in the Thorax: Pneumothorax and Pneumomediastinum as a Complication of COVID-19.

INTRODUCTION: The abnormal presence of free air in the thorax, pneumothorax, and pneumomediastinum are complications for critically ill patients suffering from coronavirus disease 2019 (COVID-19). The development of these events may lead to a poor prognosis and make the management of this category of patients more difficult. STUDY DESIGN: We performed an observational retrospective study, including patients with SARS-CoV-2 infection and pneumonia who were hospitalized, to analyze the cases that developed pneumothorax or pneumomediastinum as a complication. RESULTS: A total of 28 cases (1.51%) from 1844 patients with SARS-CoV-2 pneumonia developed pneumothorax or pneumomediastinum during hospitalization. Of them, 21 (75%) needed intensive care unit admission and ventilation, and 10 (35.71) were cured. CONCLUSION: The male gender is more probable to be involved in the development of pneumothorax or pneumomediastinum in patients with SARS-CoV-2 pneumonia. The incidence of these events is low, and conservative treatment could provide a better outcome.

Opportunity for healthy ageing: lessening the burden of adult pneumococcal disease in Central and Eastern Europe, and Israel.

The population of the Region (Central Europe, Eastern Europe, and Israel) is ageing, necessitating preventative programmes to maintain a healthy and active lifestyle in older age groups. Invasive pneumococcal disease (including bacteremic pneumonia, bacteremia without a focus, and meningitis) has higher incidence, morbidity and mortality in older adults and is a substantial public health burden in the ageing population. Surveillance in the Region establishes a significant burden in older adults of invasive pneumococcal disease (IPD), which still appears to be under-estimated as compared with other countries, and this warrants an improvement in surveillance systems. The largest proportion of IPD in adults is bacteremic pneumonia. Community-acquired pneumonia (CAP), largely attributable to S. pneumoniae, can be bacteremic or non-bacteremic; the non-bacteremic forms of CAP also represent a significant burden in the Region. The burden of pneumococcal disease can be reduced with programmes of effective vaccination. Recommendations on pneumococcal vaccination in adults vary widely across the Region. The main barrier to implementation of vaccination programmes is low awareness among healthcare professionals on serious heatlh consequences of adult pneumococcal disease and of vaccination options. The Expert Panel calls on healthcare providers in the Region to improve pneumococcal surveillance, optimize and disseminate recommendations for adult vaccination, and support awareness and education programmes about adult pneumococcal disease.

Efficacy and safety of inhaled formoterol 4.5 and 9 µg twice daily in Japanese and European COPD patients: phase III study results.

BACKGROUND: This study evaluated the efficacy and safety of the long-acting ß2-agonist formoterol in patients with moderate-to-severe COPD. METHODS: This double-blind, placebo-controlled, parallel-group, multinational phase III study randomized patients ≥ 40 years of age with moderate-to-severe COPD to inhaled formoterol 4.5 or 9 µg twice daily (bid) via Turbuhaler or placebo for 12 weeks. Salbutamol 100 µg/actuation via pMDI was permitted as reliever medication. The primary outcome variable was change (ratio) from baseline to treatment period in FEV1 60-min post-dose. RESULTS: 613 patients received treatment (formoterol 4.5 µg n = 206; 9 µg n = 199; placebo n = 208); 539 (87.9%) male; 324 (52.9%) Japanese and 289 (47.1%) European. End of study increases in FEV1 60-min post-dose were significantly greater (p < 0.001 for both) with formoterol 4.5 and 9 µg bid (113% of baseline for both) than with placebo, as were all secondary outcome measures. The proportion of patients with an improvement in St George's Respiratory Questionnaire score of ≥ 4 was 50.2% for formoterol 4.5 µg (p = 0.0682 vs. placebo), 59.2% (p = 0.0004) for 9 µg, and 41.3% for placebo. Reduction in reliever medication use was significantly greater with formoterol vs. placebo (9 µg: -0.548, p < 0.001; 4.5 µg: -0.274, p = 0.027), with 9 µg being significantly superior to 4.5 µg (-0.274, p = 0.029). Formoterol was well tolerated with the incidence and type of adverse events not being different for the three groups. CONCLUSIONS: Formoterol 4.5 µg and 9 µg bid was effective and well tolerated in patients with COPD; there was no difference between formoterol doses for the primary endpoint; however, an added value of formoterol 9 µg over 4.5 µg bid was observed for some secondary endpoints. TRIAL REGISTRATION: NCT00628862 (ClinicalTrials.gov); D5122C00001 (AstraZeneca Study code).

MicroDSC study of Staphylococcus epidermidis growth.

BACKGROUND: A microcalorimetric study was carried out using a Staphylococcus epidermidis population to determine the reproducibility of bacterial growth and the variability of the results within certain experimental parameters (temperature, bacterial concentration, sample thermal history). Reproducibility tests were performed as series of experiments within the same conditions using either freshly prepared populations or samples kept in cold storage. In both cases, the samples were obtained by serial dilution from a concentrated TSB bacterial inoculum incubated overnight. RESULTS: The results show that experiments are fairly reproducible and that specimens can be preserved at low temperatures (1 - 2°C) at least 4 days. The thermal signal variations at different temperatures and initial bacterial concentrations obey a set of rules that we identified. CONCLUSION: Our study adds to the accumulating data and confirms available results of isothermal microcalorimetry applications in microbiology and can be used to standardize this method for either research or clinical setting.

Predictors of Long-term Mortality after Hospitalization for Severe COPD Exacerbation.

Introduction:Chronic obstructive pulmonary disease (COPD) is a global health problem resulting in significant morbidity. Acute exacerbation of COPD (AECOPD) is a severe complication associated with increased short- and long-term mortality. Identifying predictors of long-term mortality after a severe AECOPD may improve management and long-term outcome of this disease. Materials and methods:A two-year prospective cohort study was undertaken in an academical medical center between 2016 and 2018. Patients with severe AECOPD who required non-invasive ventilation (NIV) were included. Baseline characteristics at inclusion, comorbidities (kidney dysfunction, left heart disease, diabetes), number of prior episodes of AECOPD and indication for long-term oxygen therapy (LTOT) or non-invasive ventilation (LTNIV) were recorded. Patients were monitored for a two-year period after initial admission. Outcomes were six-month, one-year and two-year mortality, irrespective of cause. Outcomes:51 patients (31 male, mean age 68.1) were included in the study. Mortality rates at six months, one year and two years were 20, 26 and 36%, respectively. Patients receiving LTOT and LTNIV at discharge had lower mortality at two years versus patients with no indication for LTOT and LTNIV at discharge. Absence of LTOT increased six-month mortality (OR .2, 95% CI, .04 to .90) and one-year mortality (p<.05). FEV1 and BMI were also correlated with long-term mortality in univariate analysis, p<.05. Age, number of prior episodes of AECOPD or the presence of comorbidities had no influence on long-term mortality. Conclusion:After an episode of severe AECOPD, LTOT is associated with lower long-term mortality when compared to patients with no severe hypoxemia at discharge. A decreased lung function and body mass index increase long-term mortality.

An overview of resistance profiles ESKAPE pathogens from 2010-2015 in a tertiary respiratory center in Romania.

Lower respiratory tract infections (LRTIs) is an umbrella term that covers a wide spectrum of diseases, comprising mild and severe, acute and chronic conditions. A wide spectrum of pathogens can be implicated, from viruses to pyogenic and atypical bacteria. A special place should be reserved for slow growing bacteria (Mycobacteria spp., Nocardia spp.) and parasites (i.e., hydatic cysts caused by Echinococcus granulosus). OBJECTIVE: The objective of this study is to observe, analyze and establish the drug susceptibility patterns for Enterococcus spp., Staphylococcus aureus, Klebsiella spp., Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp. (the ESKAPE pathogens) in the "Marius Nasta" Institute for Pulmonary Medicine (MNIPM), Bucharest, Romania. MATERIALS AND METHODS: A retrospective healthcare record based study was undertaken to establish the drug susceptibility patterns. We assessed all antibiograms of the ESKAPE pathogens isolated from respiratory samples from adult inpatients hospitalized between 2010-2015 at the MNIPM. RESULTS: We analyzed 2859 isolates (61% of the 4683 ESKAPE isolates). P. aeruginosa was the most frequent pathogen, while Enterococcus spp. and Enterobacter spp. were practically non-present. The antibiotic profile of P. aeruginosa isolates presented more resistance in the Intensive Care Unit (ICU)÷Surgery wards, probably resulting from antibiotic pressure. The other non-fermenter, A. baumannii, while less frequent (and the only pathogen more frequent in the surgery department) had an even more resistant profile, to almost all antibiotics, with the exception of Colistin. Methicillin-resistant S. aureus (MRSA) accounted for about 60% of all isolates, more in the ICU÷Surgery ward. K. pneumoniae presents a less resistance and shows more stability when analyzing the antibiogram pattern in the Medical wards. DISCUSSION: For methodological or procedural reasons, Enterococcus spp. and Enterobacter spp. were underrepresented in the study. Interventional programs comprising antibiotic stewardship and active surveillance need to be implemented to alleviate the antibiotic profile. Further research needs to focus on more detailed characterization of the molecular mechanisms leading to the high resistance detailed herein. CONCLUSIONS: This study adds to the body of literature reporting the antibiotic resistance landscape in Romania, for these highly resistant pathogens.

Skin, ear and testis--unusual sites of tuberculosis.

Pulmonary localization is the most common site of tuberculosis (TB)and the most contagious form. Extrapulmonary tuberculosis with the rarest and most unexpected localizations represents a significant proportion of all cases of tuberculosis and remains an important public health problem. We report three unusual TB locations: skin, ear and testis occurred in three immunocompetent patients. In the case of skin and testicular lesions, diagnosis was based on pathological confirmation of granulomas with caseous necrosis. In the third case the diagnosis was made possible by identification of positive Acid-Fast Bacilli smear and positive culture from othic drainage fluid. The outcome at all three patients was good with antituberculous treatment. These unusual localization of tuberculosis also highlight the possibility of extrapulmonary tuberculosis as a differential diagnosis in many common diseases.

Treatment options in stage III non-small cell lung cancer.

Lung cancer is responsible for over 1 million deaths annually, worldwide. The disease becomes symptomatic in advanced stages, so the diagnosis is delayed and 90% of cases cannot benefit from a curative treatment. In NSCLC surgical resection represents the best option for long term survival in resectable stage III and in clinical stage I/II. Patients with stage IIIB or IV usually receive chemotherapy or palliative treatment. For patients with no driver mutation detected platinum based combination chemotherapy is the first choice. Definitive radiotherapy is considered an lternative for patients who are not candidates for combined modality treatment. When a stage IV cancer is diagnosed based on an isolated metastasis, the patient's benefit from the removal of the etastasis and of the primary tumor if it is resectable. The prognosis in NSLC is mainly influenced by the TNM stage at diagnosis. The rate of survival decreases in opposing correlation with the stage of the cancer. Poor performance status, reduced lung capacity, weight loss, vascular invasion are indicators for a poor prognosis

Paraneoplastic syndromes: the way to an early diagnosis of lung cancer.

Pulmonary malignancies are the leading cause of cancer mortality around the world. The late diagnosis of lung cancer, in advanced stages, is mainly due to atypical clinical presentation. Paraneoplastic syndromes have been first described in 1825, as a group of symptoms related to a malignant disease, which are not the effect of the primary neither of the metastatic tumor. The paraneoplastic syndromes have been reported in all types of lung cancer, but more frequently in small cell lung cancer, due to its origin in neuroendocrine cell precursors. The most frequent associated syndromes described in the literature are neurological and endocrine. In most patients paraneoplastic syndromes occur prior to other symptoms of malignancy. The presence or the severity of these syndromes is not correlated with the stage of cancer. Most of the paraneoplastic syndromes disappear once the primary tumor is removed and reappear in case of cancer recurrence or metastasis. This paper is a review of paraneoplastic syndromes in lung cancer.

Positive pressure therapy in patients with cardiac arrhythmias and obstructive sleep apnea.

BACKGROUND: Positive pressure therapy (CPAP) in patients with cardiac arrhythmias and obstructive sleep apnea (OSAS) may have favorable effects by correcting intermittent hypoxemia and sympathetic activation. OBJECTIVE: To assess the effect of CPAP added to pharmacological treatment in the rate control and prevention of arrhythmias recurrence in patients with OSA. MATERIALS AND METHODS: Prospective, interventional study study which included patients diagnosed with OSAS (cardiorespiratorypolygraphy, AHI>5/hour), and arrhythmias (ECG, Holter ECG), divided in two groups: group A (pharmacological therapy only) and group B (pharmacological therapy and CPAP). The patients were evaluated at enrollment (T0), at 3 and 6 months (T3 and T6) regarding the type, severity and recurrence of cardiac arrhythmias. RESULTS: 36 patients (31 men), mean age: 63.2 ± 12 years were enroled. In group A: 7 patients with ventricular extrasystoles, 8 with permanent atrial fibrillation, 1 patient with atrial flutter and 2 patients with paroxystic supraventricular tachycardia. In group B: 8 patients with ventricular extrasystoles, 5 with permanent atrial fibrillation, 2 patients with recurrent episodes of atrial fibrillation and 3 with paroxystic supraventricular tachycardia. A positive correlation (r: 0.74, p < 0.001) between Oxygen Desaturation Index and AHI was found. At T6, 12 patients from group B, and 18 from group A were evaluated. In group B, the mean heart rate in patients with atrial fibrillation was 69/min., lower than in group A (82/min.), no cases with recurrent atrial fibrillation were found, and more patients with class II Lown ventricular extrasystoles passed in class I Lown, compared to group A. In group B, heart rate statistically correlated with AHI (r: 0.53, p < 0.005). CONCLUSION: In patients with OSAS, adding CPAP to pharmacological therapy has favorable effects on preventing recurrences, heart rate control in patients with atrial fibrillation and in reducing frequency and/or severity of ventricular extrasystoles.

[Evidences related to pulmonary rehabilitation in the respiratory pathology]. / Evidente legate de reabilitarea pulmonara în patologia respiratorie.

Pulmonary rehabilitation represents a modern therapeutic approach of respiratory diseases, with a multidisciplinary character, including: physical training, therapeutic education, psychosocial counseling, and nutritional approach. Pulmonary rehabilitation addresses to any patient suffering from pulmonary pathology whose quality of life is affected by the respiratory symptoms, regardless of the degree of functional impairment. This article is an analysis of evidences from the medical literature on outcomes of rehabilitation programs conducted in various lung diseases. The main indication of pulmonary rehabilitation is the chronic obstructive pulmonary disease - COPD (stable state and exacerbation) in which most studies were carried out. Pulmonary rehabilitation in patients with other respiratory pathology has its reason in the pathophysiological changes that they undergo (impaired lung function and gas exchange, muscle atrophy and deconditioning etc.) leading to symptoms, lower exercise tolerance and decrease daily physical activity, all of which ultimately result in impaired quality of life. The role of rehabilitation is reviewed in the following diseases: post-surgical lung volume reduction for emphysema, asthma, bronchiectasis, interstitial lung disease, cystic fibrosis, lung cancer, neuromuscular disease, intensive care, obstructive sleep apnea, pulmonary hypertension, post-tuberculous sequelae, lung transplantation.

[Operability in chronic thromboembolic pulmonary hypertension]. / Operabilitate în hipertensiunea pulmonara cronica postembolica.

UNLABELLED: We present the case of a 86-year-old male patient diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH) with proximal bilateral obstructions of the pulmonary arteries. The history included systemic hypertension, benign prostate adenoma and in situ colonic adenocarcinoma, cured by local radiotherapy; no prior history of thromboembolic disease was noted. The work-up comprised of a detailed analysis of pulmonary hemodynamics and right ventricular function by echocardiography and right heart catheterization, imagistic evaluation of the pulmonary circulation by contrast tomography, but also a complete evaluation of the left heart, respiratory function, neurologic status, liver and kidney function. A new colonoscopy confirmed the absence of relapse of the colonic carcinoma. The only curative therapy in proximal CTEPH is pulmonary endarterectomy, a very complex surgical procedures available in only a few centres worldwide. The case was discussed in a multidisciplinary meeting and the indications for surgery were based on exercise tolerance impairment, surgically accessible thrombi, absence of comorbidities and patient informed consent. The limits for the intervention were considered the extreme age and oncological history. The procedure was performed in Cardiovascular surgical department Timisoara, by prof. dr. Walter Klepetko and prof. dr. Marian Gappar, with good clinical and hemodinamic outcome. We present the post surgical side effects and the most important functional parameters of the follow-up. CONCLUSION: pulmonary endarterectomy should be evaluated initially in all patients diagnosed with CTEPH and the old age should not be considered an absolute contraindication if no other significant comorbidities are identified.

Complete therapeutical approach in pulmonary arterial hypertension: from vasodilators to lung transplantation - case report.

We present the case of a 37 years old patient with idiopathic pulmonary arterial hypertension (PAH). After initial treatment with calcium channel blockers (CCB), based on a positive vasoreactive response at right heart catheterization, due to disease progression, major vasodilator therapies were introduced in a sequential strategy: sildenafil, bosentan and treprostinil. Finally, the patient received double-lung transplantation with eventually favourable evolution despite immediate postoperative significant complications. Markers of disease progression were monitored before the transplant, and after the intervention the patient was screened according to a specific protocol for bronchiolitis obliterans and infections. According to our knowledge, this case represents a premiere in Romanian medicine, being the first lung transplant in a PAH patient. This case represents a model of PAH with a documented evolution of 8 years. We present the progression of the disease and the effective therapeutic strategies according to the current guidelines. This case reinforces the need for upgrading the Romanian National PAH Program with the inclusion of prostanoid therapy, as an option for severe patients.

[Uptodate in the management and treatment of ANCA-associated vasculitis]. / Noutati în managementul si tratamentul vasculitelor asociate cu ANCA.

The antineutrophil cytoplasm antibody (ANCA)-associated vasculitis are heterogeneous, multisystem, autoimmune diseases characterized by necrotizing small and medium vessel vasculitis and the association with ANCA. The diagnosis and management of these patients may be challenging due to the variability of clinical features, the possibility of life-threatening events (acute renal failure or pulmonary hemorrhage) and the relative rarity of these syndromes. ANCA-associated vasculitis include granulomatosis with polyangiitis, microscopic polyangiitis and eosinophilic granulomatosis with polyangiitis. The treatment requires significant immunosuppression and there are frequent treatment related side effects. Although the standard protocol with cytotoxic agents and glucocorticoids has dramatically improved patient outcome, its toxic profile remains a major problem. Recent progress in evidence base and consensus in understanding the pathogenic mechanism and the quantification of disease activity further improved patient's life. Special attention was paid in refining immunosuppressive treatment to minimize his toxicity. This review will focus on evidence based treatment of ANCA-associated vasculitis.

Body composition in patients with chronic obstructive pulmonary disease.

OBJECTIVES: Body composition assessment in chronic obstructive pulmonary disease (COPD) is important, as weight loss and muscular wasting are responsible for low exercise capacity in these patients, and low body mass index (BMI) and fat free mass index (FFMI) are important prognostic factors. Our study aims were: (a) to describe body composition in COPD patients referred to a pulmonary rehabilitation center in Bucharest; (b) to examine the relationships between body composition and disease severity (bronchial obstruction, exercise capacity, quality of life); (c) to test if segmental wasting of lower limbs muscle mass (measured by segmental body composition analysis) correlates with decreased exercise capacity. MATERIAL AND METHODS: We studied 36 consecutive COPD patients referred to our clinic for pulmonary rehabilitation. Patients performed pulmonary function tests, six minutes walking test (6MWT), and health status was evaluated with COPD Assessment Test (CAT). Body composition measurements were performed by direct segmental multi-frequency bioelectrical impedance analysis (BIA). OUTCOMES: This study offers the first data on body composition of Romanian COPD patientsThe prevalence of nutritional depletion (defined by low BMI and/or low FFMI) among our COPD patients was 22.2%. Mean FFMI was significantly lower in normal or underweight patients versus overweight or obese patients. Patients with low FFMI had lower exercise capacity at the 6MWT and higher CAT scores than patients with normal FFMI.Depending on the BMI and FFMI values the patients were divided in four categories: normal, semistarvation, sarcopenia and cachexia. The group of patients with sarcopenia (low FFMI and normal BMI) had the lowest mean MIP (Maximal Inspiratory Pressure), the lowest mean 6MWD (six minutes walking distance) and the higher CAT mean scores among all groups. Exercise capacity was significantly lower in muscular depleted patients (with low skeletal muscle mass index - SSMI). MIP correlated significantly with FFMI and SMMI. No correlations were found between parameters of body composition and FEV1 or CAT. Segmental body composition assessment revealed that unbalanced upper/lower skeletal muscle mass is associated with a lower exercise capacity as measured by 6WMT. CONCLUSIONS: This study offers the first data on body composition of Romanian COPD patients. The prevalence of nutritional depletion is similar to that found in other European studies. No significant correlations were found between FFMI and severity of the disease (bronchial obstruction, distance walked, CAT score). FFMI and SSMI correlated significantly with MIP. Sarcopenic patients had the lowest mean 6MWD, the lowest mean MIP and the highest CAT mean scores. SMMI significantly correlated with 6MWD. Segmental body composition assessment of revealed that "unbalanced" patients had lower results at 6MWT. These results show that body composition evaluation is useful for the assessment of COPD patients referred to pulmonary rehabilitation and should be routinely performed.