Non-high risk PE in the patients with acute or exacerbated respiratory disease: the value of the algorithm based on D-dimer evaluation and Revised Geneva Score

INTRODUCTION

The diagnostic algorithm of non-high risk pulmonary embolism (PE) is based on probability scoring systems and plasma D-dimer (DD) assessment. The aim of the present study was to investigate the efficacy of Revised Geneva Scoring (RGS) and DD testing for the excluding of non-high risk PE, in the patients admitted to the hospital due to acute respiratory diseases.

MATERIAL AND METHODS

The consecutive patients, above 18 years of age, referred to the department of lung diseases, entered the study. The exclusion criteria were: the pregnancy and the suspicion of high risk PE. Plasma DD was measured with quick ELISA test, VIDAS D-dimer New, bioMerieux, France. Multislice computed tomography angiography was performed in all of the patients.

RESULTS

153 patients, median age 65 (19-88) years entered the study. The probability of PE was: low - in 58 patients (38%), intermediate - in 90 (59%), high - in 5 (3%). DD < 500 ng/ml was found in 12% of patients with low and intermediate probability of PE. PE was recognized in 10 out of 153 patients (7%). None of the patients with DD < 500 ng/ml was diagnosed with PE (NPV 100%). Median DD value was significantly higher in PE patients comparing to non-PE (4500 ng/ml and 1356 ng/ml respectively, p = 0.006).

CONCLUSION

In the group of the patients with acute respiratory symptoms, low or intermediate clinical probability scoring combined with normal DD had a high NPV in excluding PE. Nevertheless, such approach was not very effective, as the increased DD was noted in 88% of the examined population.

What Factors May Influence Epidemiological Situation of Tuberculosis in Poland and in the World?

The authors present the review of factors influencing epidemiological situation of tuberculosis in Poland and in the world. The groups of increased risk of tuberculosis, and clinical conditions predisposing to activation of latent tuberculosis infection (LTBI) such as HIV, uremia, diabetes mellitus, transplantation of organs, treatment with glucocorticosteroids and with antibodies to TNF and to its receptors, were presented. The higher prevalence and worse prognosis of tuberculosis in elderly people was emphasised. The methods of LTBI recognition, according to recent recommendations, with special consideration to patients in immunosupression, were shown. Methods of treatment to prevent LTBI activation, according to WHO experts, were also presented. All data were discussed in relation to the actual epidemiological situation of tuberculosis in Poland.

Low DLCO in Idiopathic Pulmonary Arterial Hypertension—Clinical Correlates and Prognostic Significance

Introduction: Decreased diffusing capacity of the lung for carbon monoxide (DLCO) is observed in some idiopathic pulmonary arterial hypertension (IPAH) patients, but its clinical significance is uncertain. We aimed to assess clinical correlates and prognostic significance of low DLCO in IPAH patients. Material and methods: In the group of 65 IPAH patients the cut off value for low DLCO was set up based on histogram as <55% of predicted value. Demographic data, exercise capacity, lung function tests, hemodynamic parameters and survival of the patients were compared depending on DLCO value. Results: Low DLCO was found in 18% of the patients, and it was associated with male sex, older age, worse functional status and exercise capacity, and higher prevalence of coronary artery disease. Low DLCO carried a 4-fold increase of death risk in 5-year perspective. Conclusions: Low DLCO was a marker of worse functional capacity and increased risk of death in studied IPAH patients.

Pulmonary pathology in patients with ulcerative colitis treated with mesalazine--a challenging and complex diagnostic problem. Case series and literature review

Pulmonary involvement in the course of inflammatory bowel disease has been a subject of interest to clinicians for long time, but despite this, its epidemiology and potential pathomechanisms remain obscured. Equally unclear is the role of medications used for bowel disease treatment in lung disease development. We present three patients with ulcerative colitis, all treated with mesalazine, in whom unexplained lung disease developed. Due to different clinical and radiological presentation, different conditions were initially placed on the top of the differential list in each of them. The outcome was favourable in all patients despite differences in management. We compared our patients with similar cases from literature. We show the level of difficulty and complexity in the issue of lung disease in patients with inflammatory bowel disease.

Outcome of Medically Versus Surgically Treated Patients With Chronic Thromboembolic Pulmonary Hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is an ominous disease leading to progressive right heart failure. Selected patients can be treated by pulmonary endarterectomy (PEA). We assessed long-term clinical outcome of patients with CTEPH who underwent PEA and patients who remained on medical treatment alone. A total of 112 consecutive patients with CTEPH referred between 1998 and 2008 to one center were followed for a mean of 35 (range 0-128) months after diagnosis. All the patients had advanced pulmonary hypertension at baseline. The operated group had higher World Health Organization functional class compared to the nonoperated group. No other differences in hemodynamic, echocardiographic, or biochemical parameters were observed at baseline. Despite the perioperative mortality rate of 9.1%, patients who underwent PEA had significantly lower long-term mortality compared to nonoperated patients (12.7% vs 34.8%; P = .003), and PEA survivors showed sustained clinical improvement. All efforts should be undertaken to perform PEA in all patients with operable CTEPH.

Nadciśnienie Płucne w Przebiegu Chorób Płuc—Jdna czy Wiele Przyczyn?

Nadciśnienie płucne występujące w przebiegu chorób płuc (PH-LD, pulmonary hypertension asso-ciated with lung diseases) stanowi istotny problem diagnostyczny i terapeutyczny [...]

Rozpoznawanie i leczenie tamponady serca w przebiegu choroby nowotworowej

Tamponada serca jest stanem zagrożenia życia wymagającym pilnego leczenia zabiegowego [...]

[Acute lupus pneumonitis--case report and literature review]

Systemic lupus erythematosus (SLE) is an autoimmune connective tissue disease that is characterized by its chronic course and the involvement of many organs and systems. The most common abnormality in the respiratory system of SLE patients is lupus pleuritis. Less common is parenchymal involvement, which may present as acute lupus pneumonitis (ALP) or chronic interstitial lung disease. Other possible pulmonary manifestations of SLE include pulmonary embolism, diffuse alveolar haemorrhage, acute reversible hypoxaemia, and shrinking lung syndrome. We present the case report of a young woman with previously diagnosed membranous glomerulonephritis with nephrotic syndrome and antiphospholipid syndrome, who was admitted with marked of shortness of breath. The diagnostic process, including imaging studies and laboratory tests, enabled us to confirm a diagnosis of ALP. After initiation of treatment with high doses of methyloprednisolone, nearly complete remission of pulmonary changes was observed. We also perform a literature review regarding acute lupus pneumonitis.

Normal D-Dimer Concentration in Hospitalized Patients with Lung Diseases

Introduction: D-dimer testing is an established method in diagnostics of suspected pulmonary embolism (PE). However, in hospitalized patients, increased D-dimer concentration may be caused by comorbidities, which limits the applicability of this test in PE diagnostics. According to published data, calculating the index D-dimer/fibrinogen ratio can increase specificity of D-dimer testing in diagnostics of venous thromboembolism (VTE). The aim of the present study was: (1) to determine the frequency of normal D-dimer concentration in hospitalized patients with lung diseases in whom the differential diagnostics of PE can be particularly difficult; and (2) to evaluate the utility of D-dimer/fibrinogen ratio in subgroups of patients with acute VTE or with lung cancer. Materials and methods: The study group included 619 consecutive patients aged 54.9 (±15.4) years, hospitalized in a pulmonology reference centre. Among them there were 96 (15%) patients with acute VTE, 65 (10%) with exacerbation of COPD, and 172 (27%) with lung cancer. Results: Mean D-dimer concentration (Vidas D-dimer New) was 1956 ± 3691 ng/mL and median value was 842 (45–35,678) ng//mL. Normal D-dimer concentration (<500 ng/mL) was found in 225/523 (43%) patients without acute VTE. In 49% (32/65) patients with COPD and in 25% (43/172) patients with lung cancer, D-dimer concentration was below 500 ng/ml. Ddimer/ fibrinogen ratio was significantly higher in acute VTE patients compared to lung cancer patients (808 ± 688 and 289 ± 260, respectively; p < 0.001). Conclusions: Normal D-dimer concentration was found in more than 40% of patients with lung diseases hospitalized in the reference pulmonology centre. This observation can suggest a better utility of D-dimer measurement for PE exclusion in such a population than that seen in previously published reports. D-dimer/fibrinogen ratio is significantly higher in acute VTE than in lung cancer, but the clinical value of this test requires further evaluation.

[Normal D-dimer concentration in hospitalized patients with lung diseases]

INTRODUCTION

The use of D-dimer testing is an established part of the diagnosis of suspected pulmonary embolism (PE). However, in hospitalized patients many various factors might be responsible for increased D-dimer concentration and they could lower utility of D-dimer in exclusion of PE in such population. According to some published data, calculating the index D-dimer/fibrinogen could increase the specificity of D-dimer in the recognition of venous thromboembolism (VTE). The aim of the present study was to determine the frequency of normal D-dimer concentration in hospitalized patients with lung diseases in whom the differential diagnosis of PE is particularly difficult and to evaluate the utility of the index D-dimer/fibrinogen in subgroups of patients: with acute VTE and with lung cancer.

MATERIAL AND METHODS

619 consecutive patients aged 54.9 (± 15.4) hospitalized in reference pulmonary center were enrolled into observation. Among them, there were 96 (15%) patients with acute VTE, 65 (10%) with exacerbation of COPD and 172 (27%) with lung cancer.

RESULTS

Mean D-dimer concentration (Vidas D-dimer New) was 1956 ± 3691 ng/ml and median value 842 (45-35 678) ng/ml. Normal D-dimer concentration (〈 500 ng/ml) was found in 225/523 (43%) without acute VTE. In 49% (32/65) patients with COPD and in 25% (43/172) patients with lung cancer D-dimer concentration was below 500 ng/ml as well. The index D-dimer/fibrinogen was significantly higher in acute VTE patients compared to lung cancer patients - 808 ± 688 and 289 ± 260 respectively, p 〈 0.001.

CONCLUSIONS

Normal D-dimer concentration was found in more than 40% of patients with lung diseases hospitalized in reference pulmonary center. This observation could suggest higher than described in the literature utility of D-dimer measurement in exclusion of PE in such a population. The value of the index D-dimer/fibrinogen, which is significantly higher in acute VTE than in lung cancer requires further evaluation to establish its clinical utility.

[Constrictive pericarditis as complication of viral respiratory infection]

A 24 year-old man with 3-months medical history of recurrent respiratory infections and pericardial effusion, despite treatment with nonsteroid anti-inflammatory drugs, was admitted to the hospital with dyspnea on exertion. On admission he presented the symptoms of right heart insufficiency. Computed tomography of the chest demonstrated a thickened pericardium. Echocardiographic examination and right heart catheterisation established the diagnosis of constrictive pericarditis. Serologic tests suggested viral aetiology. The patient was referred to cardiothoracic surgery, partial pericardiectomy was performed with marked haemodynamic improvement.

Recurrent Pericarditis—Diagnostic and Therapeutic Implications

Exudative pericarditis is the cause of 5% of admissions to accidents and emergency departments with chest pain being the presenting complaint in most of these cases [...]

Recurrent Exudative Pericarditis in the Course of Adult-Onset Still’s Disease—Two Case Reports

Exudative pericarditis is a disease of varied aetiology requiring inclusion of both infectious and non-infectious causes in its differential diagnosis. The possible diagnoses include adult-onset Still’s disease (AOSD), a rare systemic inflammatory disease of unknown aetiology. AOSD typically develops in patients between 16 and 35 years of age and is characterised by fever, arthralgia, transient salmon-coloured rash and other abnormalities including pharyngitis, serositis (particularly pleuritis and pericarditis) and laboratory abnormalities, such as elevated white blood cell count and elevated markers of inflammation. We report two cases of AOSD with recurrent exudative pericarditis.

The Cardiac Markers and Oxidative Stress Parameters in Advanced Non-Small Cell Lung Cancer Patients Receiving Cisplatin-Based Chemotherapy

INTRODUCTION

Cardiotoxicity is a well known long-term consequence of lung cancer chemotherapy, however little is known about early subclinical changes in cardiac function.

AIM

The goal of the study was to assess early cardiotoxic effects of cisplatin-containing chemotherapy in stage III and IV lung cancer patients, measuring serum levels of selected cardiac markers in relation to oxidant effects.

METHODS

We quantified the immediate impact of chemotherapy on cardiac troponin T (TnT), creatine kinase-myocardial band (CK-MB) and N- terminal pro-brain natriuretic peptide (NT-proBNP) in blood samples obtained from 12 non-small cell lung cancer (NSCLC) patients. All markers were measured using commercially available immunoassays. To investigate the oxidant effects of cisplatin-containing chemotherapy, we evaluated reduced glutathione (GSH), nitrite (NO2), derivatives of reactive oxygen metabolites (d-ROMs) and thiols (SH). Samples were collected prior to chemotherapy and 1 day after the first cycle of cisplatin administration.

RESULTS

Chemotherapy did not cause statistically significant elevations in serum CK-MB. Serum TnT levels were undetectable at both time points in 11 out of 12 patients with a threshold of 0.01 ng/ml. In the single patient with undetectable TnT at the baseline, after the first infusion TnT level reversibly rose to 0.03 ng/ml. The pre-treatment value of NT-proBNP was slightly elevated in 7 out of 12 lung cancer patients. In 1 case NT-proBNP level significantly increased after chemotherapy (from 221.8 to 1489.0 pg/ml p<0.001), in the remaining 11 patients it was stable Cisplatin-based combination chemotherapy induced significant nitrite production in 5 patients (p<0.05). The other measured oxidative stress parameters remained unchanged after the first infusion.

CONCLUSION

This pilot study demonstrated occasional elevations of cardiac biomarkers during cisplatin administration. Administration of cisplatin-containing chemotherapy caused significant nitroxidative stress in some patients. The relevance of cardiovascular complications in cancer patients and identification individual risk factors of developing cardiovascular toxicity merit further evaluation.

Nowości z Kongresu ERS w Barcelonie, 18–22 Września 2010 (Część I)

Podczas Kongresu Europejskiego Towarzystwa Płucnego (ERS, European Respiratory Society) zostałam wybrana Delegatem Narodowym Polski na 3-letnią kadencję [...]

[Recurrent effusive pericarditis in the course of adult-onset Still's disease--case reports of two patients]

Pericardial effusion is caused by various pathological agents. In differential diagnosis infectious as well as non-infectious factors have to be considered. Adult-onset Still disease (AOSD)--relatively uncommon systemic inflammatory disorder of unknown etiology--is among possible diagnosis. The disease typically affects patients in the age between 16-35 years and is characterized by spiking fever, arthralgia, evanescent salmon rash with other abnormalities including pharingitis, serositis (especially pleuritis and pericarditis) and leucocytosis as well as increased serum levels of inflammatory indicators. We present two patients with recurrent pericardial effusion in the course of AOSD.