Palliative and End-of-Life Care Conversations with Older People with Chronic Obstructive Pulmonary Disease in Croatia-A Pilot Study.

Despite the progressive nature of chronic obstructive pulmonary disease (COPD), its association of high morbidity and mortality with severe COPD, and the view that discussions between patients and clinicians about palliative care plans should be grounded in patients' preferences, many older patients do not receive timely end-of-life care (EOLC) discussions with healthcare professionals (HPs), potentially risking inadequate care at the advanced stages of the disease. The aim of this pilot study was to evaluate EOLC discussions and resuscitation issues as a representative and illustrative part within EOLC in older patients with COPD in the University Hospital Center Osijek, Slavonia (Eastern Region), Croatia, as such data have not yet been explored. The study was designed as cross-sectional research. Two groups of participants, namely, patients at least 65 years old with COPD and healthcare professionals, were interviewed anonymously. In total, 83 participants (22 HPs and 61 patients with COPD) were included in the study. According to the results, 77% of patients reported that they had not had EOLC discussions with HPs, 64% expressed the opinion that they would like such conversations, and the best timing for such discussion would be during frequent hospital admissions. Furthermore, 77% of HPs thought that EOLC communication is important, but only 14% actually discussed such issues with their patients because most of them felt uncomfortable starting such a topic. The majority of older patients with COPD did not discuss advanced care planning with their HPs, even though the majority of them would like to have such a discussion. EOLC between HPs and older patients with COPD should be encouraged in line with patients' wishes, with the aim to improve their quality of care by anticipating patients' likely future needs in a timely manner and thereby providing proactive support in accordance with patients' preferences.

Predictors of short-term LAMA ineffectiveness in treatment naïve patients with moderate to severe COPD.

BACKGROUND: No specific (only subgroup) recommendations for the use of long-acting muscarinic antagonists in chronic obstructive pulmonary disease (COPD) exist. The aim of this exploratory hypothesis generating study was to assess whether different phenotypic/endotypic characteristics could be determinants of the short-term ineffectiveness of the initial tiotropium bromide monotherapy in treatment naïve moderate to severe COPD patients. METHODS: A total of 51 consecutively recruited COPD patients were followed for 3 months after the initial evaluation and prescribed initial treatment (tiotropium). Short-term treatment ineffectiveness was assessed as a composite measure comprising COPD exacerbations, need for additional treatment, and no improvement in functional parameters, e.g. 6­min walking test (6MWT), body-mass index, airflow obstruction, dyspnea, and exercise (BODE) index and forced expiratory volume in 1 s (FEV1), and as single components. RESULTS: Treatment ineffectiveness was significantly associated with baseline hemoglobin level, COPD assessment test (CAT) score, modified Medical Research Council (mMRC) scale and BODE index (p = 0.002). Incident exacerbation during the follow-up was associated with baseline bronchoalveolar lavage fluid (BALF) alpha-amylase level and CAT score (p < 0.001), and change in treatment with leukocyte count, 6MWT desaturation and fatigue (p < 0.001). No improvement in 6MWT was associated with baseline CAT score, body mass index, mMRC, fatigue, 6MWT and BODE index (p = 0.002). No improvement in BODE index was associated with leukocyte count, serum interleukin 8 (IL-8) and BALF albumin levels (p < 0.001); and no improvement in FEV1 with CAT score, baseline vital capacity and BALF tumor necrosis factor alpha (TNF-alpha) level (p < 0.001). CONCLUSION: Our results suggest that there is a possibility to identify predictors of short-term tiotropium ineffectiveness in patients with moderate to severe COPD.

Mood disorders in adult asthma phenotypes.

OBJECTIVE: Studies show high comorbidity of mood disorders in asthma. As asthma is a highly heterogeneous disease with different phenotypes it can be expected that there is a difference in this association with different asthma phenotypes. The aim of our cross-sectional study was to assess the association of specific asthma phenotypes with anxiety and/or depression and their impact on asthma control. METHODS: A cross-sectional study in 201 consecutive adult outpatients with asthma (≥18 years of age) was conducted. Each patient underwent physical examination, detailed medical history, Hospital Anxiety and Depression Scale, Asthma Control Questionnaire, Asthma Control Test, together with measurements of lung function and fraction of exhaled nitric oxide. Phenotypes were assessed using cluster analysis, and a multivariate analysis was used to identify associations of mood disorders with different phenotypes. RESULTS: Five asthma phenotypes were identified: allergic (AA, 43.8%), aspirin-exacerbated respiratory disease (AERD, 21.9%), late-onset (LOA, 18.9%), obesity-associated (OAA, 10.0%), and respiratory infections associated asthma (RIAA, 5.5%). A multivariate analysis showed a significant association of anxiety with LOA and comorbid hypertension (LOA, odds ratio (OR) = 2.12; hypertension, OR = 2.37, p = 0.012), and depression with AA, RIAA, hypertension, and ACQ score (AA, OR = 6.07; RIAA, OR = 4.73; hypertension, OR = 5.67; ACQ, OR = 1.87; p < 0.001). Comorbid anxiety/depression was associated with AA, LOA, RIAA, hypertension, and ACQ score (AA, OR = 10.15; LOA, OR = 2.98; RIAA, OR = 6.29; hypertension, OR = 5.15; ACQ, OR = 1.90; p < 0.001. CONCLUSION: Mood disorders were significantly associated with AA, LOA, and infection-associated asthma, together with comorbid hypertension and the level of asthma control.

Long-term predictors of anxiety and depression in adult patients with asthma.

BACKGROUND: It is well established that anxiety and depression are associated with asthma, but there is limited evidence about the persistence of anxiety/depression in asthma. The aim of our study was to assess the long-term predictors of anxiety and depression in adult asthmatic patients. METHODS: A total of 90 adult asthma patients (63 women, age 18-50 years) with different levels of disease control (28 uncontrolled and 34 partially controlled) were assessed at baseline and at follow-up after 7 years for anxiety, depression and asthma control. The same work-up on both occasions included: demographics, living conditions, medical history (e.g. comorbidities, adherence and exacerbations), Hospital Anxiety and Depression Scale (HADS), Asthma Quality of Life Questionnaire (AQLQ), disease control and lung function. Persistence was defined as the HADS scores for anxiety and depression present at baseline and follow-up. RESULTS: The HADS results at follow-up visit showed 36 (40%) asthma patients with anxiety and 13 (14%) with depression, with the persistence of anxiety in 17 (19%) and of depression in 7 (8%) patients. Significant predictors of anxiety at follow-up were HADS and AQLQ results at baseline and several parameters of asthma control at follow-up (area under the curve AUC 0.917, 95% confidence interval CI 0.829-0.969, p < 0.001) and for depression AQLQ mood disorder domain, asthma control and lung function (AUC 0.947, 95% CI 0.870-0.986, p < 0.001). CONCLUSION: Anxiety and depression persist over years in some patients with asthma. The association between mood disorders and asthma suggests potential mutual treatability.

Complications of pulmonary AVMs in a patient with Rendu-Osler-Weber disease.

Rendu-Osler-Weber disease, also called hereditary hemorrhagic telangiectasia (HHT), is a rare, genetically determined complex disease with a spectrum of associated manifestations which extend beyond the typical pathology of arteriovenosus malformations (AVMs). Our subject, a 54-year-old male patient with a long history of HHT has a typical mucocutaneous telangiectasias and bleeding from the nose, but the most important manifestations of the disease are those related to pulmonary AVMs. A variety of complications, such as hypoxemia, polycythemia, cyanosis, clubbing fingers and brain abscesses, have developed over time as a consequence of a-v shunt in the pulmonary AVMs. A large pulmonary AVM necessitated a surgical intervention when the patient was in his thirties, and two more surgeries followed later, due to brain abscesses. Despite intensive manifestations of the disease and episodes of life threatening complications, the patient has adjusted well to his chronic medical condition and lives a near-normal life.

Assessment of endothelial dysfunction by measuring von Willebrand factor and exhaled nitric oxide in patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a multisystemic disease, one of the leading causes of mortality and morbidity. The aim of this research is to assess the level of markers of endothelial dysfunction, vWf and the exhaled nitric oxide (NO) depending on the severity of COPD. The study included 100 subjects: 60 patients with COPD without adjoining cardiovascular comorbidity, and 40 patients as the controls. The subjects underwent a fractional exhaled nitric oxide test (FeNO), spirometric testing, and diffusing capacity of the lung for carbon monoxide test (DLCO), samples were taken of their vein blood to analyze the level of vWf (using the vWf:RCO method), C-reactive protein (CRP), fibrinogen, cholesterol, triglycerides as well as the acid base status. COPD patients then filled COPD assessment test (CAT test) and the modified dyspnea scale (mMRC). The results showed that in patient group that higher levels of vWf are associated with lower values of exhaled NO, which means that higher levels of vWf are associated with lower values of exhaled NO. By comparing the ill subjects from four groups (A, B, C and D), a difference was established between the level of vWf [F (3.56 = 0.24; p = 0.869], while, although statistically not significant, the highest level of exhaled NO was found in group A and the lowest in group D. The rise in the value of vWf is followed by the rise of fibrinogen values, which is another marker of endothelial dysfunction. The results of this research have shown that a systemic inflammation and hypoxia in the early stages of COPD, when no significant changes in the absolute values of FEV1 are present, stipulate the existence of endothelial dysfunction together with the clinically relevant differences in the levels of vWf and exhaled NO.

[Guidelines for diagnosis and management of asthma in adults of the Croatian Respiratory Society]. / Smjernice Hrvatskoga pulmoloskog drustva za dijagnosticiranje i lijecenje astme u odraslih.

The global use of guidelines for proper diagnosis and management of asthma was worldwide aimed toward obtaining effective control of asthma. Until now, the most often used guidelines in Croatia were the ones issued by the Global Initiative for Asthma (GINA). Their implementation significantly improved and uniformed the diagnosis and management of asthma at different levels of the national health system. The obtained level of knowledge has enabled the making of local guidelines which acknowledge economic, cultural and even traditional specificities of Croatia. It was supposed that Croatian medical professionals would more effectively use guidelines they actively supported to prepare and which were appropriated to local work environment and medicines available. Therefore, based on current scientific evidence, the Croatian Respiratory Society has prepared Croatian Guidelines for Diagnosis and Management of Asthma in Adults purposed for wide use among Croatian doctors and other health professionals.

[Lung lesions in penetrating war injuries of the chest]. / Ozljede pluca kod ratnih penetrantnih trauma prsnog kosa.

Presentation is made of 157 patients with lung parenchymal lesions due to penetrating war injuries of the chest, 50.3% civilians and 49.3% soldiers. The wounds were mostly inflicted by cluster projectiles (71.4%), followed by firearms (25.5%) and sharp instruments (3.1%). The injuries were characterized as a combination of laceration and lung contusion. In case of lung laceration, a moderate to massive hemopneumothorax develops. Clinically, the manifestation of lung contusion may range from hardly observable dyspnea and hemophthisis through tachypnea, tachycardia and cyanosis. Most lesions of pulmonary parenchyma can be managed by thoracic drainage, whereas in case of massive bleeding and air loss thoracotomy and appropriate operative procedures are recommended. We used anterolateral thoracotomy as a sparing procedure, which involves minimal thoracic wall disintegration. When deciding on the choice of surgical procedures for the lesions of pulmonary parenchyma, care was taken to ensure to maximally spare the intact parenchyma. Minor resections (sutures, atypical resection, segmentectomies) were performed in 92%, whereas major resection (lobectomy, pulmectomy) had to be performed in 8% of thoracotomized patients. Rethoracotomy was done in two patients due to postoperative hemorrhage. The patient submitted to pulmectomy because of the hilus vasculature lesion died after the surgery. Early resuscitation, volume and blood replacement, rapid diagnosis, and early surgical intervention are the crucial factors that influence survival in patients with lung lesions due to penetrating injuries of the thorax.