Delays in Diagnosis and Treatment in Patients Underwent Endobronchial Ultrasound-Transbronchial Needle Aspiration (EBUS-TBNA).

Objectives: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been recognized as the first method of choice in the diagnosis of mediastinal and hilar lesions. Although the procedure is commonly used, there is no study assessing its contribution to the duration required for diagnosis and treatment. In this study, we aimed to determine the extent of diagnosis and treatment delays when using the EBUS-TBNA procedure and to address the possible factors contributing to these delays. Materials and Methods: The demographic data, pathological diagnosis, need for additional procedures, symptoms, presenting complaints, and the time until the beginning of treatment were recorded retrospectively in all patients who had undergone EBUS-TBNA. Results: A total of 134 patients (mean age 60.7 ± 12 years, M/F: 78/56) were included. Delay of the patients was found in 60.4% (n = 81), delayed referral in 35.8% (n = 48), diagnosis delays in 84.3% (n = 113), treatment delays in 38.8% (n = 52), and total delay in 73.1% (n = 98) of the patients. A statistically significant association was found between referral delay and total delay with age groups (p=0.006) and between patient delay and the presence of symptoms (p=0.027). EBUS-TBNA was found to have the lowest effect among all delay parameters (ß: 0.104, p < 0.001) in the regression analysis. When diagnosis times' subgroups were compared, EBUS-TBNA was found to have the least effect (correlation coefficient: 0.134, p=0.004). Conclusion: We found that approximately ¾ of the patients had a delay and this is not acceptable in real terms. Considering that the patient burden is increasing day by day, it is necessary to make a radical change in health care or a change in strategy in order to prevent delays. EBUS-TBNA, which is in the diagnosis delay subgroup, is less invasive and accelerates the process.

Prognostic value of inflammatory markers determined during diagnosis in patients with sarcoidosis: chronic versus remission.

OBJECTIVE: This study aimed to evaluate the prognostic value of inflammatory markers determined during admission among patients with sarcoidosis with chronic and remission groups. METHODS: This study was designed as retrospective single-center study. Patients with sarcoidosis without treatment and who had at least two years of follow-up were included in this study. Patients were divided into two groups as chronic and remission. The primary outcome is to evaluate hematological parameters in remission and chronic sarcoidosis groups. RESULTS: Out of 348 patients with sarcoidosis, 142 patients without treatment and followed up for at least two years were included in this study. Groups had similar demographic features with the predominance of females (80.4 and 77.9%, respectively) and stage I disease (78.6 and 68.6%, respectively). Lymphocyte count [median (IQR) 1.7 (1.3-2.3) 109/L versus 2.1 (1.6-2.4) 109/L, p=0.034] was significantly lower, whereas neutrophil to lymphocyte ratio (NLR) was significantly higher [median (IQR) 2.6 (2.0-3.1) versus 2.0 (1.6-2.8), p=0.006] at admission in the chronic group. No significant difference was determined in inflammatory parameters at admission between groups. CONCLUSION: Lower lymphocyte count and higher neutrophil to lymphocyte ratio were determined in patients with chronic sarcoidosis compared with the remission group, based on monitoring of radiological staging up to five-year after the initial diagnosis. Accordingly, the identification of neutrophil to lymphocyte ratio at diagnosis seems to be a potential prognostic marker in patients with sarcoidosis beside its low cost and easy determination in routine clinical practice.

Contribution of aspiration to the diagnosis of lung cancer in endobronchial ultrasound-guided fine-needle biopsy.

OBJECTIVE: Endobronchial ultrasound-guided transbronchial needle aspiration has been successfully applied in both diagnosis and staging of mediastinal and hilar lymphadenopathies and masses, especially in malignant cases. However, the optimal procedure of Endobronchial ultrasound-guided transbronchial needle aspiration to further increase diagnostic yield and minimize processing complexity remains controversial. This study aims to compare aspiration biopsy (Endobronchial ultrasound-guided transbronchial needle aspiration) and non-aspiration biopsy (Endobronchial ultrasound-guided transbronchial needle capillary sampling) in terms of sample adequacy, diagnosis, and quality in malignant cases. METHODS: Between March 2018 and June 2020, Endobronchial ultrasound-guided was performed sequentially on patients with mediastinal and/or hilar lymph nodes that were considered malignant. Each lymphadenopathy was sampled with and without aspiration. A single-blinded pathologist evaluated the samples. RESULTS: A total of 84 lymph nodes evaluations of 51 patients were included. Most samples were taken from the right lower paratracheal lymph nodes (n=27, 32.2%) and subcarinal LN (n=21, 25%). The mean size of the lymph nodes was 21.21±8.257 (8-40) mm. The agreement between the two procedures in terms of sample adequacy and diagnostic yield was 69.1% (95%CI 58-78.7, p=0.076). In addition, according to the goodness-of-fit statistics, the kappa values were 0.255 (p=0.015) and 0.302 (p=0.004) for sample adequacy and diagnostic yield, respectively. There was no difference between the two procedures in relation to complications. CONCLUSION: Although the agreement between the two procedures is weak, Endobronchial ultrasound-guided transbronchial needle capillary sampling can be performed with less personnel, without reducing diagnostic yield and tissue adequacy. These findings can assist clinicians in determining the optimal procedure for Endobronchial ultrasound-guided.

Can red blood cell distribution width (RDW) level predict the severity of acute exacerbation of chronic obstructive pulmonary disease (AECOPD)?

BACKGROUND: Elevated red blood cell distribution width (RDW) levels were associated with mortality in patients with stable chronic obstructive lung pulmonary diseases (COPD). There are limited data about RDW levels in acute exacerbation of COPD (AECOPD). AIM/OBJECTIVE: The association of the RDW levels with the severity of AECOPD was evaluated according to admission location, (outpatient-clinic, ward and intensive care unit (ICU)). METHODS: Cross sectional retrospective study was designed in tertiary care hospital for chest diseases in 2015. Previously COPD diagnosed patients admitted to hospital outpatient-clinic, ward and ICU due to AECOPD were included in the study. Patients demographics, RDW, biomarkers (CRP, RDW, Neutrophil to lymphocyte ratio (NLR), platelet to mean platelet volume (PLT-MPV)) C-CRP, biochemistry values were recorded from hospital electronic system. RDW values were subdivided below 0.11% (low), above and equal 0.15% (high) and between 0.11%-0.15% (normal). Neutrophil to lymphocyte ratio (NLR) and platelet to mean platelet volume (PLT-MPV) were also calculated. Biomarker values were compared according to where AECOPD was treated. RESULTS: 2771 COPD patients (33% female) and 1429 outpatients-clinic, 1156 ward and 186 ICU were enrolled in the study. The median RDW values in outpatients-clinic, ward and ICU were 0.16 (0.09-0.26), 0.07 (0.01-0.14) and 0.01 (0.00-0.07) respectively (P < .001). In outpatient to ward and ICU, low RDW values were significantly increased (31%, 66%, 83%, respectively) and high RDW values significantly decreased (54%, 24%, 10%) (P < .001). According to attack severity, low RDW values were determined. CONCLUSION: Patients with AECOPD, lower RDW values should be considered carefully. Lower RDW can be used for decision of COPD exacerbation severity and follow up treatment response.

Clinical Characteristics and Outcomes of Liver Transplantation Recipients With COVID-19 Pneumonia.

BACKGROUND: We aimed to evaluate the clinical characteristics and outcomes of mild-severe COVID-19 pneumonia cases in liver transplant (LT) recipients. METHODS: Ten LT recipients diagnosed as having COVID-19 pneumonia in a 6-month period in our transplantation center were included. Demographic and medical data of the recipients were retrospectively collected; clinical courses, treatment responses, and outcomes were evaluated. RESULTS: Ten LT recipients were male, had a median age of 57 years (min-max, 36-69 years; interquartile range [IQR], 13 years), and had right lobe from living donor LT performed in a median of 11 months (min-max, 1-72 months; IQR, 12 months). Five patients had severe pneumonia, and the remaining patients had mild/moderate pneumonia. The most frequent symptoms were fever (90%) and cough (70%). Favipiravir, enoxaparin sodium, and corticosteroid were initiated at the time of the diagnosis; immunosuppressive drug doses were reduced or discontinued in 3 cases. Lymphopenia median: 510/mL (min-max, 90-1400 mL; IQR, 610 mL), increased levels of C-reactive protein median: 4.72 (min-max, 0.31-23.4; IQR, 8.5), and ferritin median: 641 (min-max, 40 to ≥ 1650; IQR, 1108) were frequent. Four patients required antibacterial treatments because of emerging bacterial pneumonia and/or sepsis. All patients were hospitalized for a median of 10 days. One patient with sepsis died on the 26th day after intensive care unit admission, and the remaining 9 survived. No further complication was recorded for 1-month follow-up. CONCLUSIONS: Commencing favipiravir, enoxaparin sodium, and corticosteroid treatments; close follow-up of the developing complications; the temporary reduction or cessation of immunosuppression; a multidisciplinary approach; early awareness of the bacterial infections; and the initiation appropriate antibiotic treatments can contribute to success.

Differential diagnosis of COVID-19 pneumonia from acute heart failure in pandemic: Importance of radiological and laboratory findings.

INTRODUCTION: COVID-19 pneumonia typically presents with high fever, cough, and shortness of breath and on thorax computed tomography (CT) peripheral ground glass opacities help the diagnosis. Although typical imaging findings for COVID-19 pneumonia are specified in thorax CT, these findings can be confused with other diseases. The aim of this study is to investigate the roles of radiological imaging and laboratory findings in the differential diagnosis of COVID-19 pneumonia and acute heart failure (AHF). MATERIALS AND METHODS: In the present study, 74 patients who admitted to the emergency department with respiratory distress during the pandemic period and received a diagnosis of COVID-19 pneumonia and AHF were included. Laboratory data and radiological findings of the patients, at the time of admission, were evaluated. RESULT: On admission, there was no difference in age, gender between two groups. However, COVID-19 exposure history was found significantly higher in COVID-19 pneumonia patients group (p<0.001). Fever, cough, and fatigue were found significantly higher in the COVID-19 pneumonia patients group (p<0.001). There was difference of lesions distribution between the two groups, centrally distributed lesions were found significantly higher in acute heart failure patients (p<0.001). Pleural effusion and cardiomegaly were found significantly higher in AHF patients (p<0.001, p<0.001). Counts of the white blood cells and lymphocytes were found significantly lower in COVID-19 pneumonia patients (p= 0.003, p= 0.009). COVID-19 pneumonia patients had significantly higher levels of CRP, ferritin, LDH and CK compared with AHF patients (p<0.001, p<0.001, p= 0.002, p= 0.013). However the level of NT-proBNP was found significantly higher in the AHF patients group (p<0.001). CONCLUSIONS: We believe that laboratory data and thorax CT findings can provide beneficial clinical information in differentiating COVID-19 pneumonia from AHF during the pandemic.

Short-term experiences of a liver transplant centre before and after the COVID-19 pandemic.

BACKGROUND/AIM: With the COVID-19 pandemic, managing the process of solid organ transplantation has become a significant matter for transplant centres. In this study, we report our experiences on evaluating the effects of COVID-19 in patients with recent liver transplants. MATERIALS AND METHODS: We evaluated patients who received liver transplants during three close consecutive periods of time. For transplants conducted between October 1 and December 31, 2019, January 1 and March 10, 2020 and March 11 and June 22, 2020, the lung tomographies of patients were inspected for radiological signs of viral pneumonia. For patients after March 11, 2020, the hospital's electronic database system was scanned for preoperative and postoperative SARS-CoV-2 testing from Real-time Polymerase Chain Reaction (RT-PCR) of the respiratory tract samples. RESULTS: A total of 149 patients over the age of 18 who received liver transplants at our centre between October 1, 2019 and June 22, 2020 were evaluated. During this time span, our centre conducted liver transplants on patients from 34 different provinces and also abroad. Within this time period, a total of nine patients had respiratory samples with a positive SARS-CoV-2 RT-PCR test. PCR of respiratory tract samples was performed in 21 (14%) patients to identify the other potential infective agents in the respiratory tracts; Rhinovirus and Influenza A were detected in two and respiratory syncytial virus (RSV) was detected in one patient. During the transplant periods, 99 (67.1%) patients were evaluated with computed tomography (CT). The CT findings of 18 (12%) patients were consistent with viral pneumonia. There was a statistically significant difference between the groups only in terms of air bronchogram findings (P = .012). CONCLUSION: The clinical status of our short-term liver transplant patients was far better than we originally anticipated, but it remains obvious that the necessary precautions should continue to be taken.

Excess Deaths in Malatya in the COVID-19 Pandemic.

OBJECTIVE: In our study, the effects of the COVID-19 pandemic in Malatya province, other than confirmed case deaths, were investigated. MATERIAL AND METHODS: The records of those who died between 2016 and 2020 were reviewed on the official website of the Malatya Metropolitan Municipality, and the numbers of deaths in those 5 years were recorded on a weekly basis. The arithmetic mean of the deaths between 2016 and 2019 was calculated, and it was investigated whether the number of deaths in 2020 was more than expected. RESULTS: In 2020, 1743 (61%) excess deaths were detected. While the mean number of deaths reported 4 years before 2020 was 2860, it was determined that the number of deaths in 2020 was 4603, and there were 1743 (61%) excess deaths. CONCLUSION: The deaths occurred in Malatya during the COVID-19 pandemic were more than expected. It has been supposed that some deaths were of polymerase chain reaction negative and hence unrecorded COVID-19 patients' deaths, and some deaths were caused by other indirect effects of the pandemic.

[Mortality prediction ability of phycians in intensive care units of Turkey (MOPAP)]. / Türkiye'de yogun bakim ünitelerinde hekimin mortaliteyi öngörebilme gücü.

INTRODUCTION: Intensive care physicians are increasingly involved in decision making about the prognosis of intensive care unit ICU patients. With this study; we aimed to evaluate the power of clinician foresight at prediction of mortality in patient at triage to intensive care and patient follow-up. MATERIALS AND METHODS: This study was conducted in ICUs located in various geographical regions of Turkey between January 1, 2017-April 30, 2017.The clinical research was planned as observational, multicenter, cross-sectional. RESULT: A total of 1169 intubated patients were followed in 37 different ICU. At the beginning of the follow-up we asked the physician who will follow the patient in the ICU to give a score for the probability of survival of the patients. Scoring included a total of 6 scores from 0 to 5, with the "0" the worst probability "5" being the best. According to this distribution, only 1 (0.9%) of 113 patients who were given 0 points survived. Three (6.1%) of 49 with the best score of 5 died. Survival rates were significantly different in each score group (r: -0.488; p<0.001). After the combined mortality estimation scores based on the clinical observations of the physicians (0 and 1 point score was combined as non-survive, 4 and 5 score was combined as survived) 320 of the 545 patients were estimated to be dead and 225 were predicted survival. Sensitivity and spesifity of scoring system to predict mortality was 91.56% (95% CI: 87.96-94.37), 76.89% (95% CI: 70.82-82.23) respectively. CONCLUSIONS: In this study, we concluded that the physicians who follow the patients in the ICU can predict the poor prognosis at the time of admission and the high mortality rate. The physician's opinion on mortality estimation should be considered in intensive care mortality scoring in addition to other laboratory and clinical parameters.

Cytomegalovirus associated severe pneumonia in three liver transplant recipients.

INTRODUCTION: Cytomegalovirus (CMV), is the most common opportunistic infection, remains a cause of life-threatening disease and allograft rejection in liver transplant (LT) recipients. The purpose of this case series is to state that CMV may lead to severe pneumonia along with other bacteria. METHODOLOGY: CMV pneumonia was diagnosed with the thoracic computed tomography (CT) scan findings, bronchoscopic biopsy, real time quantitative Polymerase Chain Reaction (qPCR) and clinical symptoms. For extraction of CMV DNA from the clinical sample, EZ1 Virus Mini Kit v2.0 (Qiagen, Germany) was used, and aplification was performed with CMV QS-RGQ Kit (Qiagen, Germany) on Rotor Gene Q 5 Plex HMR (Qiagen, Germany) device. RESULTS: All recipients had severe pneumonia, leukopenia, thrombocytopenia and at least two-fold increase in transaminases on seventh, twenty-eighth and twenty-second days after surgery, respectively. Thoracic CT scan revealed as diffuse interstitial infiltration in the lung parenchyma. Bronchoscopy, Gram-staining and culture from bronchoalveolar lavage (BAL) fluid were performed in all of them. During bronchoscopy, a bronchial biopsy was administered to two recipients. One recipient could not be performed procedure because of deep thrombocytopenia. PCR results were positive from serum and BAL fluid. Bronchial biopsy was compatible with CMV pneumonia. However, Pseudomonas aeruginosae was found in two cases and Klebsiella pneumoniae in one case BAL fluid cultures. CONCLUSIONS: CMV pneumonia can be seen simultaneously with bacterial agents due to the indirect effects of the CMV. It should be kept in mind that CMV pneumonia may cause severe clinical courses and can be mortal.

A Revised Treatment Approach for Hospitalized Patients with Eosinophilic and Neutrophilic Exacerbations of Chronic Obstructive Pulmonary Disease.

OBJECTIVES: The choice of treatment according to the inflammation type in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) has been of recent interest. This study investigated the role of novel biomarkers, hospital outcomes, and readmission rates in the first month in patients with eosinophilic or neutrophilic AECOPD. MATERIALS AND METHODS: We conducted a retrospective observational cohort study in a Chest Teaching Hospital with hospitalized AECOPD patients. Subjects' characteristics, hemogram results, C-reactive protein (CRP), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), platelet/mean platelet volume (PLT/MPV), length of hospital stay, mortality, and steroid use were recorded. Eosinophilic AECOPD defined as peripheral blood eosinophilia (PBE) was >2% and neutrophilic AECOPD as PBE ≤2%. Readmission within 28 days of discharge was recorded. RESULTS: Of 2727(31.5% females) patients, eosinophilic AECOPD was found in 510 (18.7%) patients. Leucocytes, CRP, NLR, and PLR were significantly higher in neutrophilic AECOPD than in eosinophilic AECOPD (p<0.001). Steroid use and mortality rate were 45% and 0.6% in eosinophilic AECOPD and 71%, and 1.4% in neutrophilic AECOPD, respectively (p=0.001, p=0.19). Age >75 years, albumin <2.5 g/dL, CRP >50 mg/dL, and PLT/MPV <20×103 were found to be risks factors for hospital mortality (p<0.05 each). Readmission rates within 28 days of discharge were 5% (n=136), and this rate was higher in eosinophilic AECOPD patients not taking steroids (p<0.001). CONCLUSION: NLR, PLR, and CRP levels were higher in neutrophilic AECOPD compared with eosinophilic AECOPD. These markers decreased with treatment in neutrophilic AECOPD. A PLT/MPV ratio of <20×103 resulted in an increased mortality rate. Thus, appropriate steroid therapy may reduce readmission rates in the first 28 days after discharge in eosinophilic AECOPD.

Analysis of Age Distribution and Disease Presentation of 1269 Patients with Sarcoidosis.

OBJECTIVE: While the incidence of sarcoidosis peaks between 20 and 39 years, it is comparatively low in elderly subjects. We sought to determine whether there are age-dependent differences in the demographic and laboratory characteristics of patients with sarcoidosis. MATERIALS AND METHODS: We retrospectively collected information from our database using the International Classification of Disease (ICD) diagnostic code D86 between 2008 and 2014. Patients were divided into three groups: 20-39 years old (Group 1), 40-59 years old (Group 2), and 60-80 years old (Group 3). RESULTS: A total of 3988 patients with code of D86 were included in the study. After the exclusion of non-eligible patients, the number of cases in Groups 1, 2, and 3 were 276, 641, and 352, respectively. The groups were compared according to demographic characteristics, ICD diagnostic codes, and laboratory parameters. The ratio of female patients was significantly higher in Group 3 than in Groups 1 and 2 (p=0.000). There was no difference in diagnostic codes of the ICD subgroups between groups (p=0.19). While the level of blood-urea nitrogen was significantly higher in Group 3 patients than in other groups (p=0.000), serum angiotensin-converting enzyme (ACE) values were found to be significantly low in Group 3 (p=0.010). The mean ACE values did not differ between females and males (50.8±39.3 and 59.1±45.5 mg/dL, respectively) (p=0.18). CONCLUSION: The majority of patients with sarcoidosis were female in all age groups and pulmonary sarcoidosis was the most common presentation of the disease. Elderly patients (≥60 years) with sarcoidosis had lower serum ACE levels than younger patients.

[Lung carcinoma patients aged eighty years over and prognostic factors affecting survival]. / Seksen yas üzerindeki akciger kanseri olgulari ve sagkalimi etkileyen faktörler.

INTRODUCTION: Almost 50% of all cancers and 70% of cancer deaths occur in cases aged 65 years and more. Thus diagnosis, treatment and follow up in old cases gain importance. Since there a limited number of study that show age-mortality relation in lung cancer cases aged 80 years and over, issues may arise in diagnosis and treatment process of these cases. In this study, we aimed to evaluate general characteristics of lung cancer cases aged 80 years or over and factors that affect survey. MATERIALS AND METHODS: Between 2010 and 2013, the retrospective cohort study was done in Sureyyapasa Chest Diseases and Chest Surgery Training and Research Hospital and 100 cases of lung carcinoma were examined. RESULT: In the study, 70% of the cases were male and 30% were female. Median age was 83 ± 2.91 (80-92) years. 71% of the cases were found to be suffering from a comorbid disease; 29% did not have any comorbid disease. Dyspnea (56%), cough (50%) and chest pain (41%) were the most frequent symptoms. Histopathologically, 41% of the patients diagnosed with adenocarcinoma and 40% were diagnosed with squamous cell carcinoma. Median survival time was 2.73 months (%95 CI 0.96-4.49) and 1-year survival rate was 17%. Length of time of the cases with smoking history was found shorter than of cases without smoking history (p= 0.013). Life expectancy of the cases with advanced disease and performance score of 3-4 was detected to be short (p= 0.006, p< 0.001). Compared to the cases who operated on and had chemoradiotherapy, length of life who had symptomatic treatment was shorter (p< 0.001). CONCLUSIONS: Despite the comorbidity in lung cancer cases aged 80 years and over, life expectancy of the cases who had surgical and/or chemoradiotherapy treatment is longer. While deciding on treatment methods on these cases, patient's performance must be taken into consideration.

A comparison of propofol-midazolam and midazolam alone for sedation in endobronchial ultrasound-guided transbronchial needle aspiration: a retrospective cohort study.

OBJECTIVES: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new, minimally invasive, bronchoscopic technique used in the evaluation of inthrathoracic lymph nodes.Use of sedation drugs before the procedure differs among centres. There is no standardization about sedation before EBUS-TBNA.We used a policy decision to shift from use of propofol with midazolam vs midazolam alone in a large tertiary hospital to evaluate the diagnostic yield and safety of EBUS-TBNA procedure. METHODS: Files of all the patients who were performed EBUS-TBNA between the dates of September 2010 and May 2014 were surveyed. All the EBUS-TBNA cases were performed under sedation of propofol and midazolam with an accompanying anesthesiologist in the beginning, however, sedation is applied with midazolam without an accompanying anesthesiologist after April 2013 due to changes in sedation policy. The diagnostic yield and complication rates were compared by chi-squared analysis between two groups. RESULTS: The files of 340 EBUS-TBNA performed patients were evaluated. Of the patients 274 eligible patients were analysed. 152 patients who fulfilled the inclusion criteria were analysed in propofol-midazolam (P) sedated group and 122 patients were analysed in midazolam (M) group. There is no statistically significant difference between two different sedated groups in terms of age and gender. Diagnostic value was detected as 77.6% in P group and 85.7% in M group and the difference was not statistically significant. No difference between complication rates of both groups was observed. CONCLUSION: Both sedation-types for performing EBUS-TBNA showed similar diagnostic value and complication rates in our study. Propofol with midazolam application requires with an accompanying anaesthesiologist, therefore, it increases cost. EBUS-TBNA procedures had been performed in safe with no decrease in diagnostic yield under moderate sedation.

Supervivencia en exacerbaciones de la enfermedad pulmonar obstructiva crónica que requirieron ventilación no invasiva en planta / Patient Outcome after Chronic Obstructive Pulmonary Disease Exacerbations Requiring Non-invasive Ventilation during Hospitalization

Introducción: La introducción de la ventilación no invasiva (VNI) durante las exacerbaciones agudas hipercápnicas de la enfermedad pulmonar obstructiva crónica (EPOC) en plantas de hospitalización general ha demostrado ser eficaz, pero hay escasos datos sobre el pronóstico de estos pacientes. El objetivo de este estudio fue investigar la evolución intrahospitalaria y a largo plazo de pacientes con exacerbaciones de la EPOC que requirieron terapia VNI durante su ingreso en plantas de hospitalización general. Métodos: En este estudio de cohortes retrospectivo y unicéntrico se incluyó a pacientes con exacerbaciones hipercápnicas de la EPOC ingresados en planta entre los años 2011 y 2013. Se recabaron datos clínicos, analíticos y de supervivencia tras una mediana de 27 meses y se analizaron los factores predictivos de la mortalidad durante el ingreso y a largo plazo. Resultados: Se registraron datos de un total de 574pacientes (357varones, edad media 68±11 años). Durante el periodo de hospitalización fallecieron 24pacientes (4,1%). Se observó que la mortalidad durante la hospitalización era mayor en los pacientes que presentaban concentraciones de hematocrito y albúmina más bajas y recuentos leucocitarios más altos en el momento del ingreso, y en aquellos con pH bajo y PaCO2 alta 24h más tarde. La mediana de tiempo de supervivencia de esta cohorte fue de 27meses. Las tasas de mortalidad a los 3 y 6meses y a un año fueron del 14,5, 19,5 y 30%, respectivamente. En el análisis univariante, se observó que la menor supervivencia a largo plazo estaba relacionada con la edad avanzada, un índice de Charlson alto y concentraciones de hematocrito y albúmina bajas en el momento del ingreso, y un pH bajo al cabo de 24h. En el análisis multivariante, los factores de predicción de la mortalidad más sólidos fueron la edad avanzada y las bajas concentraciones de albúmina. Conclusión: Tras una exacerbación de la EPOC que haya requerido VNI, la esperanza de vida es corta. El hemograma inicial y los resultados de la gasometría arterial del segundo día pueden pronosticar la mortalidad durante la hospitalización. Los indicadores más sólidos de mala evolución a largo plazo son la edad avanzada y las bajas concentraciones de albúmina. Es posible que estos pacientes requieran un seguimiento más estrecho

Introduction: Noninvasive ventilation (NIV) during hospitalization for acute hypercapnic exacerbations of chronic obstructive pulmonary disease (COPD) has been shown to be effective, but data on the prognosis of such patients is limited. The aim of this study was to investigate in-hospital and long-term outcome in patients with COPD exacerbations requiring NIV treatment during hospitalization. Methods: Between 2011 and 2013, hospitalized subjects with hypercapnic COPD exacerbations were included in this retrospective single-center cohort study. Subjects’ clinical and laboratory data and survival status after a median of 27 months were recorded. The predictive factors of in-hospital and long-term mortality were analyzed. Results: A total of 574 patients (357 men, mean age 68±11 years) were recorded. During hospitalization, 24 (4.1%) patients died. In-hospital mortality was negatively affected by lower baseline values of hematocrit, albumin, and pH, and by higher baseline leucocytes and higher 24h PaCO2. Median survival of the cohort was 27 months. Mortality at 3 and 6 months, and 1 year were 14.5%, 19.5%, and 30%, respectively. In the univariate analysis, reduction in long-term survival was found to be related to older age, higher Charlson score, lower baseline levels of hematocrit and albumin, and lower pH level after 24h. In the multivariate analysis, older age and lower albumin were identified as the strongest predictors of mortality. Conclusion: Life expectancy after a COPD exacerbation requiring NIV treatment is short. Baseline blood counts and day 2 arterial blood gases levels may predict in-hospital mortality. The strongest indicators of poorer long-term outcome were advanced age and lower albumin. Such patients may need closer follow-up

Can patients with moderate to severe acute respiratory failure from COPD be treated safely with noninvasive mechanical ventilation on the ward?

PURPOSE: Noninvasive mechanical ventilation (NIMV) usage outside of intensive care unit is not recommended in patients with COPD for severe acute respiratory failure (ARF). We assessed the factors associated with failure of NIMV in patients with ARF and severe acidosis admitted to the emergency department and followed on respiratory ward. PATIENTS AND METHODS: This is a retrospective observational cohort study conducted in a tertiary teaching hospital specialized in chest diseases and thoracic surgery between June 1, 2013 and May 31, 2014. COPD patients who were admitted to our emergency department due to ARF were included. Patients were grouped according to the severity of acidosis into two groups: group 1 (pH=7.20-7.25) and group 2 (pH=7.26-7.30). RESULTS: Group 1 included 59 patients (mean age: 70±10 years, 30.5% female) and group 2 included 171 patients (mean age: 67±11 years, 28.7% female). On multivariable analysis, partial arterial oxygen pressure to the inspired fractionated oxygen (PaO2/FiO2) ratio <200, delta pH value <0.30, and pH value <7.31 on control arterial blood gas after NIMV in the emergency room and peak C-reactive protein were found to be the risk factors for NIMV failure in COPD patients with ARF in the ward. CONCLUSION: NIMV is effective not only in mild respiratory failure but also with severe forms of COPD patients presenting with severe exacerbation. The determination of the failure criteria of NIMV and the expertise of the team is critical for treatment success.

The efficacy and economical benefits of blood patch pleurodesis in secondary spontaneous pneumothorax patients.

INTRODUCTION: Prolonged air leak in secondary spontaneous pneumothorax (SSP) patients remains one of the biggest challenges for thoracic surgeons. This study investigates the feasibility, effectiveness, clinical outcomes, and economical benefits of the autologous blood patch pleurodesis method in SSP. MATERIAL AND METHODS: First-episode SSP patients undergoing autologous blood patch pleurodesis for resistant air leak following underwater-seal thoracostomy, between January 2010 and June 2013 were taken into the study. Timing and success rate of pleurodesis, recurrence, additional intervention, hospital length of stay, and complications that occurred during follow-up were examined from medical records, retrospectively. RESULTS: Thirty-one (27 male, 4 female) SSP patients with expanded lungs on chest X-ray and resistant air leak on the 3(rd) post-interventional day were enrolled. Mean age was 53.7 ± 18.9 years (range: 23-81). Twenty-four patients were treated with tube thoracostomy, 2 with pezzer drain, and 5 with 8 F pleural catheter. 96.8% success was achieved; air leak in 29 of 31 patients (93.5%) ceased within the first 24 hours. No procedure-related complication such as fever, pain or empyema was seen. Late pneumothorax recurrence occurred in 4 (12.9%) patients; 1 treated with talc pleurodesis where the other 3 necessitated surgical intervention. CONCLUSIONS: Autologous blood patch pleurodesis is a safe, effective, and easily performed procedure with no need of any additional equipment or extra cost. This method can be applied to all patients with radiologically expanded lungs and continuous air leak after 48 hours following water-seal drainage thoracostomy, to reduce hospital stay duration, unnecessary surgical interventions, and the expenses.

Patient Outcome after Chronic Obstructive Pulmonary Disease Exacerbations Requiring Non-invasive Ventilation during Hospitalization. / Supervivencia en exacerbaciones de la enfermedad pulmonar obstructiva crónica que requirieron ventilación no invasiva en planta.

INTRODUCTION: Noninvasive ventilation (NIV) during hospitalization for acute hypercapnic exacerbations of chronic obstructive pulmonary disease (COPD) has been shown to be effective, but data on the prognosis of such patients is limited. The aim of this study was to investigate in-hospital and long-term outcome in patients with COPD exacerbations requiring NIV treatment during hospitalization. METHODS: Between 2011 and 2013, hospitalized subjects with hypercapnic COPD exacerbations were included in this retrospective single-center cohort study. Subjects' clinical and laboratory data and survival status after a median of 27 months were recorded. The predictive factors of in-hospital and long-term mortality were analyzed. RESULTS: A total of 574 patients (357 men, mean age 68±11 years) were recorded. During hospitalization, 24 (4.1%) patients died. In-hospital mortality was negatively affected by lower baseline values of hematocrit, albumin, and pH, and by higher baseline leucocytes and higher 24h PaCO2. Median survival of the cohort was 27 months. Mortality at 3 and 6 months, and 1 year were 14.5%, 19.5%, and 30%, respectively. In the univariate analysis, reduction in long-term survival was found to be related to older age, higher Charlson score, lower baseline levels of hematocrit and albumin, and lower pH level after 24h. In the multivariate analysis, older age and lower albumin were identified as the strongest predictors of mortality. CONCLUSION: Life expectancy after a COPD exacerbation requiring NIV treatment is short. Baseline blood counts and day 2 arterial blood gases levels may predict in-hospital mortality. The strongest indicators of poorer long-term outcome were advanced age and lower albumin. Such patients may need closer follow-up.

Case fatality rate related to nosocomial and ventilator-associated pneumonia in an ICU: a single-centre retrospective cohort study.

BACKGROUND: Nosocomial pneumonia (NP) and ventilator associated pneumonia (VAP) have been associated with financially significant economic burden and increased case fatality rate in adult intensive care units (ICUs). This study was designed to evaluate case fatality rate among patients with NP and VAP in a respiratory ICU. METHODS: In 2008-2013, VAP and NP in the ICUs were included in this retrospective single-centre cohort study. Data on demographics, co-morbidities, severity of illness, mechanical ventilation, empirical treatment, length of hospital stay and laboratory findings were recorded in each group, as were case fatality rate during ICU admission and after discharge including short-term (28-day) and long-term (a year) case fatality rate. RESULTS: A total of 108 patients with VAP (n = 64, median (IQR) age: 70 (61-75) years, 67.2% were men) or NP (n = 44, median (IQR) age: 68 (62-74) years, 68.2% were men) were found. Appropriate empirical antibiotic therapy was identified only in 45.2 and 42.9% of patients with VAP and NP, respectively. Overall case fatality rate in VAP and NP (81.3 vs 84.1), ICU case fatality rate (42.2 vs 45.5%), short-term case fatality rate (15.6 vs 27.3%) and long-term case fatality rate (23.4 vs 11.4%) were similar between VAP and NP groups along with occurrence 50% of case fatality rate cases in the first 2 months and 90% within the first year of discharge. Multivariate analysis showed that chronic obstructive pulmonary disease (COPD) (HR: 3.15, 95% CI: 1.06-9.38; p = 0.039) and presence of septic shock (HR: 3.83, 95% CI: 1.26-11.60; p = 0.018) were independently associated with lower survival. CONCLUSION: In conclusion, our findings in a retrospective cohort of respiratory ICU patients with VAP or NP revealed high ICU, short- and long-term case fatality rates within 1 year of diagnosis, regardless of the diagnosis of NP after 48 h of initial admission or after induction of ventilator support. COPD and presence of septic shock are associated with high fatality rate and our findings speculate that as increasing compliance with infection control programs and close monitoring especially in 2 months of discharge might reduce high-case fatality rate in patients with VAP and NP.

Comparison of exercise capacity in COPD and other etiologies of chronic respiratory failure requiring non-invasive mechanical ventilation at home: retrospective analysis of 1-year follow-up.

INTRODUCTION: The objective of this study was to compare the change in 6-minute walking distance (6MWD) in 1 year as an indicator of exercise capacity among patients undergoing home non-invasive mechanical ventilation (NIMV) due to chronic hypercapnic respiratory failure (CHRF) caused by different etiologies. METHODS: This retrospective cohort study was conducted in a tertiary pulmonary disease hospital in patients who had completed 1-year follow-up under home NIMV because of CHRF with different etiologies (ie, chronic obstructive pulmonary disease [COPD], obesity hypoventilation syndrome [OHS], kyphoscoliosis [KS], and diffuse parenchymal lung disease [DPLD]), between January 2011 and January 2012. The results of arterial blood gas (ABG) analyses and spirometry, and 6MWD measurements with 12-month interval were recorded from the patient files, in addition to demographics, comorbidities, and body mass indices. The groups were compared in terms of 6MWD via analysis of variance (ANOVA) and multiple linear regression (MLR) analysis (independent variables: analysis age, sex, baseline 6MWD, baseline forced expiratory volume in 1 second, and baseline partial carbon dioxide pressure, in reference to COPD group). RESULTS: A total of 105 patients with a mean age (± standard deviation) of 61±12 years of whom 37 had COPD, 34 had OHS, 20 had KS, and 14 had DPLD were included in statistical analysis. There were no significant differences between groups in the baseline and delta values of ABG and spirometry findings. Both univariate ANOVA and MLR showed that the OHS group had the lowest baseline 6MWD and the highest decrease in 1 year (linear regression coefficient -24.48; 95% CI -48.74 to -0.21, P=0.048); while the KS group had the best baseline values and the biggest improvement under home NIMV (linear regression coefficient 26.94; 95% CI -3.79 to 57.66, P=0.085). CONCLUSION: The 6MWD measurements revealed improvement in exercise capacity test in CHRF patients receiving home NIMV treatment on long-term depends on etiological diagnoses.