Whole blood samples for faster real-time PCR analysis of thrombophilic mutations in SARS-CoV-2 virus positive patients.

High incidence of thrombosis and venous thromboembolism was reported in patients with COVID-19. In this study, we focused on analysis of thrombophilic mutations performed without a standard DNA extraction step. In one hundred of COVID-19 positive outpatients, real-time PCR for Leiden mutation in the FV gene and G20210A mutation in the FII gene was carried out from DNA extracts and modified whole blood samples, and their cycle threshold (Ct) values were evaluated. In the extracts, healthy homozygotes (wt/wt), heterozygotes (M/wt), and homozygous carriers of Leiden mutation (M/M) provided median Ct values of 18.5, 19.4/22.0, and 20.9. In the whole blood, Ct values were 25.3 (wt/wt), 24.8/27.2 (M/wt), and 26.9 (M/M). Median Ct values for G20210A in the extracts were 19.6 for homozygotes (wt/wt), and 19.7/20.4 for heterozygous carriers. The whole blood samples provided Ct values of 23.9 in healthy homozygotes and 26.3/27.2 in heterozygotes for G20210A mutation. No homozygous subjects for G20210A and no double heterozygotes (for Leiden and G20210A mutations) were found. Despite significant differences in the Ct values, genotyping showed complete result concordance of the DNA extracts and the whole blood samples. The integrity and amplificability of DNA molecules in the whole blood samples during 28 days of deep freezing, interrupted by four cycles of thawing, did not significantly change. In conclusion, we demonstrated a new protocol for the detection of the thrombophilic mutations via real time PCR on the modified whole blood of COVID-19 positive patients. The blood modification was reliable, easy, cheap, and saving costs and turnaround time of the whole laboratory process.

Chylothorax treatment with thoracic duct embolization

The authors present a case of a patient with non-traumatic right-sided chylothorax which was successfully treated by thoracic duct embolization. The procedure was performed through the cisterna chyli which was visualised by intranodal lymphography. The coils and acrylic tissue glues were used for embolization. The patient has been followed for 5 months and is free of recurrence of chylothorax.

Pulmonary arteriovenous malformation managed by VATS lobectomy.

Pulmonary arteriovenous malformation (PAVM) is formed by abnormal connections between pulmonary arteries and veins that bypass the pulmonary capillaries and transport deoxygenated blood through pulmonary veins to the left heart. This causes insufficient oxygenation of blood in the lungs. This condition remains symptomless for a long period of time. The most common symptoms include shortness of breath on exertion, nosebleeds, increased fatigue and a gradual development of cyanosis. Paradoxical embolism in the brain is a serious complication; it can present with a stroke or a brain abscess. Treatment of the disease consists of embolization of the pathological vascular connections, surgical resection of the affected pulmonary parenchyma and management of concomitant manifestations of the disease. PAVM in most common cases arises as a result of an autosomal dominant hereditary disorder referred to as hereditary hemorrhagic telangiectasia.  Case report: In our communication, we document the diagnostic and therapeutic management in a young patient diagnosed with PAVM after falling off his bicycle. Based on comprehensive assessments, AV malformations with a 40% shunt of the pulmonary circulation were detected. An angiographic procedure was not an appropriate option considering the type and extent of the condition. Therefore, video-assisted thoracic resection of the affected pulmonary lobe was indicated. Conclusion: PAVM is a rare finding. PAVM should be ruled out in all patients with hereditary hemorrhagic telangiectasia (HHT) signs in the oral cavity. Contrast sonography of the heart and contract CT of the chest are the methods of choice for the diagnosis. Conservative or pharmacological treat-ment fails to improve the patients status.  The condition is usually managed by embolization. Cases where PAVM is rather extensive or diffuse, where endovascular management would be inappropriate, can be well managed using endoscopic resection adequate to the extent of the condition.

BAL fluid analysis in the identification of infectious agents in patients with hematological malignancies and pulmonary infiltrates.

The present study aims to evaluate the diagnostic yield of bronchoalveolar lavage (BAL) fluid in patients with hematological malignancies and describe the most common pathogens detected in BAL fluid (BALF.) An analysis of 480 BALF samples was performed in patients with hematological malignancies over a period of 7 years. The results of culture methods, PCR, and immunoenzymatic sandwich microplate assays for Aspergillus galactomannan (GM) in BALF were analyzed. Further, the diagnostic thresholds for Aspergillus GM and Pneumocystis jiroveci were also calculated. Microbiological findings were present in 87% of BALF samples. Possible infectious pathogens were detected in 55% of cases; 32% were classified as colonizing. No significant difference in diagnostic yield or pathogen spectrum was found between non-neutropenic and neutropenic patients. There was one significant difference in BALF findings among intensive care units (ICU) versus non-ICU patients for Aspergillus spp. (22% versus 9%, p = 0.03). The most common pathogens were Aspergillus spp. (n = 86, 33% of BAL with causative pathogens) and Streptococcus pneumoniae (n = 46, 18%); polymicrobial etiology was documented in 20% of cases. A quantitative PCR value of > 1860 cp/mL for Pneumocystis jirovecii was set as a diagnostic threshold for pneumocystis pneumonia. The absorbance index of GM in BALF of 0.5 was set as a diagnostic threshold for aspergillosis. The examination of BAL fluid revealed the presence of pathogen in more than 50% of cases and is, therefore, highly useful in this regard when concerning pulmonary infiltrates.

[The position of tiotropium in new treatment guidelines for chronic obstructive pulmonary disease]. / Pozice tiotropia v nových lécebných doporuceních pro chronickou obstrukcní plicní nemoc.

Chronic obstructive pulmonary disease is a significant syndrome of internal medicine with serious health, social and economic impacts. Globally, tiotropium is the longest used and through the randomised studies the most examined representative of inhalation long-acting antimuscarinics. In routine practice, this treatment group is identified with a globally known abbreviation LAMA (or U-LAMA, U means ultralong-acting with dosing every 24 hours). Pharmacological agents of the LAMA (U-LAMA) group are included in a significant number of all important treatment guidelines. The Czech guidelines place these medicines into the first line of general medication - for all symptomatic patients, regardless of the stage, age and comorbidities. The article describes the role of LAMA (namely tiotropium) in the treatment of chronic obstructive pulmonary disease and also relevant evidence of the efficacy and safety of both tiotropium dosage forms (HandHaler and Respimat) in detail.

[Chronic obstructive pulmonary disease in the light of new guidelines -  brief summary of phenotypically oriented guidelines for nonpulmonary physicians]. / Chronická obstrukcní plicní nemoc pohledem nových doporucení -  souhrn aktuálního fenotypove zamereného standardu Ceské pneumologické a ftizeologické spolecnosti pro internisty.

INTRODUCTION: COPD is a global health and social problem. Morbidity and mortality increases in the Czech Republic. There are currently several global statements and strategies. METHODS: The Czech Pneumological and Phthisiological Society (CPFS) at the end of 2011 mandated the Section of bronchial obstruction in drafting national guidelines concerning the stable COPD. Subsequently, this document was discussed during the National Consensus Conference (COPD forum) in November 2012 and presented at series of local workshops and national conferences. National guidelines has been subject to a review and eventually posted on the website for another round of comments. DIAGNOSIS: A modern approach to COPD is a view of the patient through the pulmonary function, symptoms, exacerbation rates and the presence of specific phenotypes. CPFS identified six clinically relevant phenotypes: frequent exacerbators, COPD and asthma overlap, COPD and bronchiectasis overlap, emphysematic phenotype, bronchitic phenotype and phenotype of pulmonary cachexia. TREATMENT: TREATMENT recommendations can be divided into four elementary steps: the first step is the Elimination of all risks factors. The second one is the Standard therapy including in particular inhaled bronchodilators, pulmonary rehabilitation, and treatment of severe comorbidities. The third step is the Targeted therapy centered on clinical phenotypes of COPD. The final fourth step is the treatment of respiratory insufficiency and palliative care of the terminal COPD. CONCLUSION: The optimal treatment of COPD requires a personalized approach to the patient.

[Treating stable chronic obstructive pulmonary disease (COPD) and its potential cardiovascular risks (a basic overview)]. / Terapie stabilní chronické obstrukcní plicní nemoci (CHOPN) a její prípadná kardiovaskulární rizika (základní prehled).

Chronic obstructive pulmonary disease (COPD) is a highly prevalent clinical syndrome. It affects a significant proportion of world population, including non-smokers. The number of COPD patients continues to grow. For many reasons, COPD is often associated with a heart disease. In some patients, a heart disease is the primary pathology, in others COPD develops first, while sometimes heart and pulmonary involvement occur more or less simultaneously. As yet we are unable to repair damaged pulmonary parenchyma or to restore capillary destruction occurring around pulmonary alveoli. Furthermore, the disease development cannot be completely suppressed. However, outpatients may be offered a range of treatment interventions leading to slower COPD progression, improvement in quality of life and longevity, and symptom and acute exacerbation risk reduction. The main aim of the paper is to present current perceptions of COPD and to discuss potential cardiovascular risks of the treatments used.

Impairment of nasal mucociliary clearance in former smokers with stable chronic obstructive pulmonary disease relates to the presence of a chronic bronchitis phenotype.

BACKGROUND: Associations between nasal and bronchial impairment have been repeatedly described in chronic obstructive pulmonary disease (COPD), whereas nasal mucociliary clearance (MCC) in COPD patients is not yet fully understood. We studied nasal MCC parameters in COPD patients and compared them with healthy adults (HA) and with cystic fibrosis (CF) patients with compromised MCC. METHODOLOGY: An observational study of 98 COPD ex-smokers and subjects from control groups evaluated for nasal MCC time (NMCCt) and by digital video microscopy of nasal mucosa recording ciliary beat frequency (CBF) and ciliary beat pattern. RESULTS: The NMCCt was decreased in HA compared to those with COPD and decreased in those with COPD compared to those with CF. CBF in COPD was lower compared to HA. The index of ciliary dyskinesia in COPD patients differed from HA. We detected higher NMCCt and lower nasal CBF in patients with chronic bronchitis phenotype (CB) compared to non-CB patients. CONCLUSIONS: We confirmed the presence of impaired nasal MCC in COPD ex-smokers. These impairments were apparent predominantly in the CB phenotype.

Failure of noninvasive prediction of pulmonary hypertension in patients with idiopathic pulmonary fibrosis.

BACKGROUND: Pulmonary hypertension (PH) in patients with advanced idiopathic pulmonary fibrosis (IPF) is a complication connected with unfavorable prognosis. Great efforts have been made in attempting to establish a reliable non-invasive method which would enable detection of this complication. In this context a formula using pulmonary function parameters was published with outstanding results. METHODS: We tested the formula in 27 IPF patients who underwent a lung function examination, cardiac ultrasonography and catheterisation on the same day. RESULTS: Pulmonary hypertension was detected by catheterisation in 17 patients (63%). In our group, contrary to the published data, the aforementioned formula was neither useful for detecting patients with a high probability of PH nor as a means of calculating the mean pulmonary artery pressure in individual patients (p = 0.502 and p = 0.833, respectively). Ultrasound examination reached borderline correlation with the values measured by catheterisation when we compare patients with relevant results (r = 0.531, p = 0.051). However, the examination gave no usable results in 13 patients (48%). CONCLUSION: Our data suggests that no reliable, noninvasive method is currently available for detecting and confirming PH in IPF patients. We did not confirm the usefulness of the published formula. Further carefully organised studies will be necessary to verify or refute it.

[Relationship between quality of life and BODE index of stable ex-smokers with chronic obstructive pulmonary disease]. / Vztah mezi kvalitou zivota a BODE indexem u bývalých kuráku ve stabilní fázi chronické obstrukcní plicní nemoci.

BACKGROUND AND AIM: This study was carried out to assess relationship between quality of life (QoL) and disease severity expressed by multifactorial prognostic index (BODE) in ex-smokers suffering from chronic obstructive pulmonary disease (COPD), minimally 8 weeks free of exacerbation. MATERIALS AND METHODS: The evaluation was performed in 98 randomly recruited COPD patients enrolled into a cross-sectional, observational CILIARY study at the Department of Pneumology, Charles University, Faculty of Medicine in Hradec Králové. In them, quality of life evaluation using the SGRQ questionnaire and the BODE index calculation was performed. We statistically compared interrelationship between BODE and COPD stages, SGRQ and COPD stages and interrelation of BODE and SGRQ. RESULTS: We found significant differences in QoL of COPD patients and QoL in group of healthy volunteers (p <0.001). Lower QoL and higher BODE score were associated with a higher stages of COPD (p < 0.001), with the exception non-significant difference in QoL (SGRQ score) and BODE index between stages I and II. Our study found positive correlation between the all SGRQ scores and multidimensional prognostic BODE index (r = 0.431-0.704). The strongest correlation (r = 0.704) was evident in activity domain of SGRQ. CONCLUSION: Our results proved close correlation ofquality of life (SGRQ) and multidimensional prognostic score (BODE) in stable COPD exsmokers' population. Both these scoring systems are useful tools for the assessment of clinical course and stratification of severity of COPD. However at present both scales are minimally used in the Czech Republic.

[Examination of function and structure of respiratory cilia of adult patients suffering from chronic obstructive pulmonary disease (COPD)--comparison of nasal and bronchial mucosa (pilot of CILIARY STUDY)]. / Porovnání struktury a funkce nazální a bronchiální sliznice u nemocných s CHOPN (pilotní projekt ciliární studie).

INTRODUCTION: Borderline between upper and lower respiratory tract pathology is probably artificial (bronchial asthma). Also inflammation of bronchial mucosa during chronic obstructive pulmonary disease (COPD) is likely combined with inflammatory involvement of nasal mucosa. Ciliary edge of respiratory epithelium is very important part of mucosa layer. AIM: To investigate and compare nasal and bronchial ciliary beat frequency (CBF), degree of nasal and bronchial ciliary dyskinesia, presence of ciliary akinesia and incidence of spinocellular metaplasia in the both mucosa localities among of stable COPD patients (pts). METHOD: Nasal and bronchial mucosa were obtained in the course of bronchoscopy examination of COPD pts in general intravenous anesthesia. Native samples of mucosa tissue were assessed by digital high-speed video microscopy (1,000x magnification). Paired t-test was used to evaluate differences in average frequencies. Significance level was alpha = 0.05. Mode was used to describe "index of dyskinesia", as a measure of association was used K coefficient. MATERIAL: Seventeen COPD pts (6 weeks free of exacerbation) at the age 47-80 (average 64.2 years +/- 9.7) were examined (13 male), average FEV1 61% predic. value (21-81, +/- 15). All patients were active smokers (average 42 pack years +/- 22.8) and all suffered from bronchitic (daily sputum production) phenotype of COPD. RESULTS: We did not find any difference in average ciliary beat frequencies between nose (6.0 Hz +/- 1.3) and bronchus (5.9 +/- 1.3) locality (p = 0.427). We find weak association between nose and bronchus in "ciliary akinesia" (kappa = 0.282) but medium association in "metaplasia" (kappa = 0.485), in index of dyskinesia (kappa = 0.733). CONCLUSION: We did not find in our data any difference in nasal and bronchial ciliary beat frequencies and we found medium association between nasal and bronchial spinocellular metaplasia and index of ciliary dyskinesia. Possible generalization of these results would require further investigation and analysis.

[Endovascular treatment of spontaneous hemothorax in patient with neurofibromatosis type I]. / Endovaskulárni lécba spontánního hemotoraxu u neurofibromatózy I. typu.

Authors present possibility of endovascular treatment of spontaneous hemothorax in the patient with neurofibromatosis type I. CT angiography was crucial in diagnostic algorithm because revealed false aneurysm of the thyreocervical artery. This artery was embolised with acrylic glue. The patient has been without signs of recurrent bleeding.

[News in the examination of the ciliary activity in the respiratory tract mucosa]. / Novinky ve vysetování aktivity rasinek sliznice respiracního traktu.

Ciliary activity assessment attracts a great interest and has undergone dynamic progress since the last decades. The ciliary function is typically impaired in primary ciliary dyskinesia (PCD). The cilia are mostly examined in vitro, the sample is taken away from the nasal mucosa. Digital videomicroscopy is accessible for the cilia observation in vitro and represents a gold standard. Manual reading using this method is lengthy in comparison with a photomultiplier. Using the photomultiplier, light captured in an optical fibre is analysed automatically by a computer. With technological progress other methods gain ground such as automatical analysis of variance of grey degrees or photomultiplier connected with a scanning confocal microscope. A medium 199 is mostly used for preservation of the functioning cilia. To retain ciliary beat frequency (CBF) it is necessary to use a heated microscope stage. Average physiological CBF value is 11.5 Hz in adult population and 12.8 Hz in children.

[Wegener's granulomatosis--a case report]. / Wegenerova granulomatóza (WG) --kazuistické sdelení.

UNLABELLED: Authors present an unusual eye finding in a 56 years old patient with Wegener's granulomatosis, who was followed up at the Department of Pulmonary Diseases, School of Medicine Hospital, Hradec Králové (Königgrätz), Czech Republic. From the point of view of the internal medicine, there are granulomas of the upper and lower airways and renal affection (minimally LK form). It consists of the affections of lungs and bronchi (histologically verified), kidneys (erytrocytouria with normal functions), eyes (ophthalmoscopically verified), weight loss about 10%, and possible nose involvement (suspect). The eye finding consists of severe anterior and posterior scleritis bilaterally, protrusion of the eyeball, and restricted movement of the left eye temporally with diplopia, and changing retinal findings bilaterally with the final improvement of consequently appearing foci of the serous retinal detachment. CONCLUSION: The paper demonstrates variety of ocular findings in Wegener's granulomatosis, and simultaneously emphasizes the importance of multidisciplinary collaboration in diagnosis and treatment of this serious disease.

[Late complications of chronic respiratory infections in patients with common variable immunodeficiency]. / Pozdní komplikace chronických zánetu respiracního traktu u nemocných s beznou variabilní imunodeficiencí.

Common variable immunodeficiency (CVID) is the most frequent serious humoral deficiency manifested in adulthood in the form of acute and chronic respiratory infections which in most patients lead to respiratory failure. Retrospective analysis of 28 CVID patients was made. Mean age at time of diagnosis was 38.6 +/- 18.6 years. The time which elapsed from the first symptoms to determining the diagnosis was three times as long as that indicated in other studies, i.e., 14.1 +/- 10.2 years. Twenty-three patients (82.1%) had respiratory complications. Chronic obstructive pulmonary diseases, n=16 (57.1%), and bronchiectasis, n=10 (35.7%), were the most frequent types of lung damage. In addition, two patients (7.1%) displayed evidence of interstitial lung process. Morbidity associated with CVID can be reduced by early diagnosis and adequate dosage of immunoglobulins to minimise the occurrence and progression of lung damage.

[The role of bronchial artery embolization in the treatment of hemoptysis]. / Postavení embolizace bronchiální tepny v terapii klinicky významné hemoptýzy.

BACKGROUND: Moderate and severe hemoptysis is a potential life-threatening condition which requires immediate medical examination and intervention. AIM: Retrospective evaluation of the effectiveness of bronchial artery embolization in the management of hemoptysis (over 50 ml per 24 hours) in the university hospital (from 1998 to 2005). METHODS: A retrospective case study. Forty seven consecutive patients with hemoptysis over 50 ml per 24 hours were reviewed and data collected from medical documentation (medical history, chest X-ray, bronchoscopy, thorax spiral CT, pulmonary and bronchial angiography). RESULTS: Forty seven patients, 34 men and 13 women aged between 19-87 years, mean age of 57.1 years, were included in this study. All patients had clinically important hemoptysis (more than 50 ml blood in 24 hours), 23 patients 50-200 ml, 14 patients 200-500 ml, 10 patients over 500 ml. Twenty eight patients had reccurent hemoptysis and nineteen patients had the first stage of hemoptysis. Within the study group we recorded the following clinical causes of hemoptysis: 12 COPD with bronchiectasis, 11 pulmonary malignancy, 11 idiopatic hemoptysis, 5 arterioarterial shunts, 3 pneumonia, 2 aspergillomas, 1 posttuberculous scars, 1 pulmonary trauma, 1 pulmonary arteriovenous malformation. All 47 patients underwent angiography. Thirty seven bronchial artery embolizations (BAE) were performed on the side with greater bronchoscopy and CT abnormality. Polyvinyl-alcohol (sponge particles 45-350 pm) or acrylate glue were used as embolizing agents. We did not observe any complication during this procedures (BAE). Immediate success i.e. cessation of hemoptysis was achieved in 36 patients (97%). Follow-up lasted 4-63 months (33 patients). BAE resulted in long-term success i.e. no recurrent hemoptysis for 28 patients (85%). CONCLUSION: Transcatheter bronchial artery embolization is an effective and safe procedure for patients suffering from clinically important hemoptysis. Short-term control of hemoptysis can be achieved in 97% and long-term control in 85% of cases. Bronchial artery embolization is a treatment which can reduce the need for acute thoracic surgery.

[Care of patients with the sleep apnea syndrome in the Czech Republic]. / Péce o pacienty se syndromem spánkové apnoe v Ceské republice.

In the Czech Republic, for ten million inhabitants there are eight sleep laboratories (two neurological, one otorhinolaryngological and five pneumological), equipped with twelve units monitoring four or eight parameters. The first OSAS laboratory was established in 1991. In 1994, health insurance began providing patients with CPAP and doctors began publicising sleep syndromes. Since 1994, 3,860 patients were examined. Patients were referred: by general practitioners (34%), by otorhinolaryngologists (16%), by pneumologists (15%) or by neurologists (12%) and 24% came voluntarily. The ratio was eight men to one woman. Nearly all came because partners requested it. Of the 3,860 examined, 740 (around 19%) began using CPAP. The criteria for using CPAP are following: an oxygen saturation in the blood below 90% for more than 20% of the sleeping period. In very serious cases BiPAP was used (27 patients--0.7%). 185 patients (4.8%) underwent surgery on soft palate.

[Diagnosis of sleep apnea syndromes at the Medical School Hospital in Hradec Kralove]. / Diagnostika syndromu spánkové apnoe ve Fakultní nemocnici v Hradci Králové.

The authors present a short review of complex diagnostic procedure of sleep apnea syndrome in Hradec Králové Faculty Hospital.