Risk assessment in inoperable chronic thromboembolic pulmonary hypertension

Background

Our objective was to investigate an abbreviated version of the the current European PH guidelines, noninvasive French model, an abridged version of the REVEAL 2.0 risk score calculator, REVEAL Lite 2, and a refined 4-strata risk assessment model, COMPERA 2.0 for inoperable chronic thromboembolic pulmonary hypertension (CTEPH).

Methods

We enrolled inoperable CTEPH patients from 8 PAH centers from December 2009 to June 2020 (n=123). 70% of patients were treated with PAH therapies. Noninvasive French model comprising WHO functional class (FC), 6-minute walk distance (6 MWD), and N-terminal pro–brain natriuretic peptide (NT-pro BNP) or BNP was used for 63 patients. REVEAL Lite 2 including FC, systolic blood pressure, heart rate, 6MWD, BNP/NT-pro BNP, and estimated glomerular filtration rate was used for 71 patients. COMPERA 2.0 including FC, 6MWD and BNP/NT-pro BNP was used for 71 patients. Patients were grouped into three categories according to the French model and REVEAL Lite 2 scores, and into four categories according to COMPERA 2.0. Kaplan-Meier (KM) survival was assessed in each risk group with all-cause mortality as the end point. Log-rank test was used to compare estimates.

Results

The mean age was 64±13 years at diagnosis. The median follow-up was 22.7 months. 26 patients had died. None of the patients had balloon pulmonary angioplasty. Most patients had received monotherapy (55%). 23.8% of patients were WHO FC I-II, 65.6% III, and 10.7% IV at initial evaluation (Table 1). All models discriminated risk in our cohort. Patients having none of low-risk criteria or high risk profiles by REVEAL Lite 2 and COMPERA 2.0 at follow-up had the worst survival. Figure 1 demonstrates KM survival curves for noninvasive French model (A), REVEAL Lite 2 (B), and COMPERA 2.0 (C). 37.3% of patients achieved 2 or more low risk criteria at follow-up. 44.8% of patients were in low risk at follow-up (REVEAL lite 2). 52.1% of patients were in low and intermediate-low risk at follow-up (COMPERA 2.0). The estimated survival rate at 5 years of patients meeting 2 and more low-risk criteria was 86% vs. 55% for patients meeting 0 low-risk criterion (p=0.04). The corresponding survival rate was 45% for high-risk patient, 79% for intermediate-risk patient, and 82% for low-risk patient (REVEAL lite 2) (p=0.029). The corresponding survival rates were 51.1% for high-risk patient and 91.6% for intermediate-low risk patient (COMPERA 2.0) (p=0.017). COMPERA 2.0 seems more accurate based on c-index. Survival was similar between patients treated and not treated with PAH therapies (p=0.735).

Conclusions

Noninvasive French model, REVEAL Lite 2, and COMPERA 2.0 may provide a simplified method of risk assessment for inoperable CTEPH. This analysis also supports the value of goal-oriented treatment in CTEPH. Patients who have not achieved low risk category at follow-up may benefit from escalation of their treatment regimen.

Funding Acknowledgement

Type of funding sources: None.

Risk assessment tool implementation in congenital heart disease associated pulmonary arterial hypertension

Background

Risk assessment is recommended for patients with congenital heart disease associated pulmonary arterial hypertension (CHD-PAH). Patients in intermediate or high risk may need intensified therapies to improve their survival.

Purpose

To compare an abbreviated version of the risk assessment strategy proposed by the current European PH guidelines, noninvasive French model, and an abridged version of the REVEAL 2.0 risk score calculator, REVEAL Lite 2.

Methods

We enrolled a mixed prevalent and incident cohort of patients with CHD-PAH from 6 PAH centers from January 2006 to December 2019 (n=126). Noninvasive French model comprising WHO functional class (FC), 6-minute walk distance (6 MWD), and N-terminal pro–brain natriuretic peptide (NT-pro BNP) or BNP was used. REVEAL Lite 2 includes FC, systolic blood pressure, heart rate, 6MWD, BNP/NT-pro BNP, and estimated glomerular filtration rate. Patients were grouped into three categories according to the number of non-invasive low-risk criteria (French model) and REVEAL Lite 2 scores. Risk was calculated based on the last available assessment at 12 months' follow-up, starting from enrollment. Kaplan-Meier (KM) survival was assessed in patients in each risk group with all-cause mortality as the end point. Log-rank test was used to compare estimates.

Results

The mean age was 32±16 years at diagnosis. The mean follow up was 99.41±58.2 months. 32 patients had died. Most patients were Eisenmenger Syndrome (39.4%) and simple defects (19.7%). Most patients had received monotherapy (74.5%). 66.6% of patients were WHO FC I–II, 29.3% III, and 3.9% IV (Table). Both models effectively discriminated risk in our cohort (p=0.0001). Patients achieving two or more noninvasive low-risk criteria or low risk category by REVEAL Lite 2 at follow-up had a significantly reduced risk of death. Figure demonstrates KM survival curves for noninvasive French model (A) and REVEAL Lite 2 (B). 51% of patients achieved 2 or more low risk criteria at follow-up. 56% of patients were in low risk at follow-up (REVEAL lite 2). The estimated survival rate at 5 years of patients meeting 2 and more low-risk criteria at follow-up was 100% vs. 86.8% for patients meeting 1 low-risk criterion and 59.6% for patients meeting 0 low-risk criterion. The corresponding survival rate was 65% for high-risk patient, 76.2% for intermediate-risk patient, and 100% for low-risk patient (REVEAL lite 2) (p=0.0001 by log-rank test; Figure). REVEAL Lite 2 approximates noninvasive French model at discriminating among patients at low, intermediate, or high risk based on c-index.

Conclusions

Both noninvasive French model and REVEAL Lite 2 provide a simplified and robust method of risk assessment for CHD-PAH. This analysis also supports the value of goal-oriented treatment in CHD-PAH. Patients who have less than 2 low-risk criteria or who have not achieved low risk category at follow-up may benefit from escalation of their treatment regimen.

Funding Acknowledgement

Type of funding sources: None.

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs.

CONCLUSIONS

Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically.

Diffusion Weighted MRI of Primary Pituitary Abscess

Pituitary abscess is a rarely seen entity that can lead to serious neuroendocrine disorders or even be fatal if not diagnosed or treated correctly. Preoperative diagnosis plays an important role in planning the operation and treatment strategies. This report describes the diagnostic value of diffusion-weighted imaging (DWI) in addition to conventional magnetic resonance imaging (MRI) of primary pituitary abscess formation caused by Klebsiella ozaenea in a 33-year-old man.

Endoscopic Removal of Duodenal Perforating Fishbone - A Case Report

BACKGROUND

Accidental ingestion of foreign bodies is common in clinical practice. While perforation of the ileum and jejunum due to the ingested foreign body is common, duodenal perforation is rare. In this report, our experience with this rare entity is shared.

CASE REPORT

Here we present a 31-year-old patient with gastrointestinal tract perforation at the second part of the duodenum due to an ingested fishbone. The patient was admitted to the emergency room with abdominal pain. Right upper quadrant tenderness was detected at physical examination, and leukocytosis on the laboratory test results. Ultra-sonography was not diagnostic, however, computerized tomo-graphy showed an ingested foreign body in the second part of the duodenum. A fishbone perforating the duodenum was retrieved by endoscopy. The patient was managed non-operatively, and discharged without any problems on the third day after endoscopy.

CONCLUSION

Endoscopic removal and non-operative management may be feasible in carefully selected patients with duodenal perforated fishbone ingestion.

Evaluation of tularaemia courses: a multicentre study from Turkey

In this multicentre study, which is the largest case series ever reported, we aimed to describe the features of tularaemia to provide detailed information. We retrospectively included 1034 patients from 41 medical centres. Before the definite diagnosis of tularaemia, tonsillitis (n = 653, 63%) and/or pharyngitis (n = 146, 14%) were the most frequent preliminary diagnoses. The most frequent clinical presentations were oropharyngeal (n = 832, 85.3%), glandular (n = 136, 13.1%) and oculoglandular (n = 105, 10.1%) forms. In 987 patients (95.5%), the lymph nodes were reported to be enlarged, most frequently at the cervical chain jugular (n = 599, 58%), submandibular (n = 401, 39%), and periauricular (n = 55, 5%). Ultrasound imaging showed hyperechoic and hypoechoic patterns (59% and 25%, respectively). Granulomatous inflammation was the most frequent histological finding (56%). The patients were previously given antibiotics for 1176 episodes, mostly with β-lactam/β-lactamase inhibitors (n = 793, 76%). Antituberculosis medications were provided in seven (2%) cases. The patients were given rational antibiotics for tularaemia after the start of symptoms, with a mean of 26.8 ± 37.5 days. Treatment failure was considered to have occurred in 495 patients (48%). The most frequent reasons for failure were the production of suppuration in the lymph nodes after the start of treatment (n = 426, 86.1%), the formation of new lymphadenomegalies under treatment (n = 146, 29.5%), and persisting complaints despite 2 weeks of treatment (n = 77, 15.6%). Fine-needle aspiration was performed in 521 patients (50%) as the most frequent drainage method. In conclusion, tularaemia is a long-lasting but curable disease in this part of the world. However, the treatment strategy still needs optimization.

Tularaemia outbreaks in Sakarya, Turkey: case-control and environmental studies

INTRODUCTION

Tularaemia is an important zoonotic disease that leads to outbreaks. This study aimed to compare the epidemiological characteristics of two tularaemia outbreaks that occurred in the Sakarya region of Turkey, analyse the risk factors for the development of outbreaks and identify Francisella (F.) tularensis in the water samples.

METHODS

Two tularaemia outbreaks occurred in the Kocadongel village in 2005 and 2006. A field investigation and a case-control study with 47 cases and 47 healthy households were performed during the second outbreak. Clinical samples from the patients and filtrated water samples were analysed for F. tularensis via real-time polymerase chain reaction.

RESULTS

From the two outbreaks, a total of 58 patients were diagnosed with oropharyngeal tularaemia based on their clinical and serological results. Both outbreaks occurred between the months of January and April, and the number of patients peaked in February. Logistic regression analysis revealed that the consumption of natural spring water was the only significant risk factor for tularaemia infection (odds ratio 3.5, confidence interval 1.23-10.07). F. tularensis was detected in eight clinical samples and in the filtrated natural spring water.

CONCLUSION

This study is the first report of tularaemia from this region. The results show that both tularaemia outbreaks were related to the consumption of untreated natural spring water. To prevent waterborne tularaemia, community water supplies should be treated and checked periodically.

Naturally occurring amino-acid substitutions to nucleos(t)ide analogues in treatment naive Turkish patients with chronic hepatitis B

Naturally occurring amino-acid substitutions in the hepatitis B virus (HBV) polymerase gene may be responsible for resistance to nucleoside/nucleotide (NUCs) analogues. To date, only pre-existing lamivudine resistance has been extensively studied. The aim of the present study was to determine the naturally occurring or pre-existing amino-acid substitutions related to NUCs in treatment naive Turkish patients with chronic hepatitis B (CHB). The investigation involved a total of 88 patients (65 males and 23 females; mean age, 34 years; range, 15-61 years) who were diagnosed with CHB between April 2008 and January 2009. According to HBeAg status, 66 patients were HBeAg-negative and 22 patients were HBeAg positive. Naturally occurring substitutions in the HBV polymerase region were detected by DNA sequencing in 17 (19%) and 30 (34%) patients, based on manual and geno2pheno tool database interpretation, respectively. Each amino-acid substitution appeared alone and included rtA194T, rtV214A, rtQ215S, rtI233V and rtN236T. The median values for viral load, ALT and AST were 3.3 log(10) (2.0-6.0) IU/mL, 36 (12-515) U/L and 27 (13-284) U/L, respectively, but these did not correlate with the observed amino-acid substitutions in the polymerase region. By direct sequencing, genotype D of HBV was found to still be dominant among Turkish patients. In conclusion, every patient who is diagnosed with CHB should be monitored before the start of treatment for more effective management of patient treatment options.

An outbreak of oropharyngeal tularaemia linked to natural spring water

A tularaemia outbreak was investigated involving 188 suspected cases in the Kocaeli region of Turkey between December 2004 and April 2005. A case-control study comprising 135 laboratory-confirmed cases and 55 controls was undertaken to identify risk factors for the development of the outbreak and to evaluate laboratory diagnostic methods. Tularaemia was confirmed by a microagglutination test (MAT) titre of >or=1 : 160 in 90 of the patients. In MAT-negative sera, 23/44 (52 %) were positive by ELISA with Francisella tularensis LPS and 1/9 (11 %) by Western blotting with this antigen. A species-specific PCR was positive in 16/25 (64 %) throat swabs and 8/13 (62 %) lymph node aspirates. Multivariate analysis showed that drinking natural spring water was the leading risk factor for the development of tularaemia (P=0.0001, odds ratio 0.165, 95 % CI 0.790-0.346). The outbreak ceased after abandonment of the suspected natural water springs.

Is there a relation between duration of cyclosporine usage and right and left ventricular function in renal transplant patients? Tissue Doppler Echocardiography study

BACKGROUND

Our aim was to investigate the effect of cyclosporine (CsA), which is commonly used in renal transplant patients and causes myocardial fibrosis and elevated arterial tension, on cardiac function.

METHODS

Sixty-six renal transplant patients (RTPs) and 25 healthy controls were included in the study. Renal transplantation patients were divided according to time of CsA exposure: group 1 (0 to 36 months); group 2 (36 to 72 months) and group 3 (> 72 months). Systolic peak velocity (Sm, mitral; St, tricuspid) and mitral early (e)/late (a) (Me/a) and tricuspid e/a (Te/a) waves of the right and the left ventricles were measured by pulse-wave (PW) Doppler used for tissue Doppler imaging of both ventricles as well as the ventricle free wall near to the lateral tricuspid and the posterior mitral leaflets. The measurements included conventional diastolic early (E) and late (A) waves and deceleration time (DT) of the E wave, isovolumetric relaxation time (IVRT) of both ventricles, as well as left ventricular systolic ejection fraction (EF).

RESULTS

There were no statistically significant differences between the groups with regard to demographic, clinical, and most biochemical characteristics. Left ventricular EF was normal in all groups; there were no statistically significant differences. IVRT and DT of left ventricle and right ventricle DT values were similar among RTPs. On the other hand, values were found to be increased in RTP groups compared with the control group. E/A ratio, Me/a Te/a of both ventricles were similar among RTPs. However, these values were found to be decreased in RTP groups compared with the control group.

CONCLUSIONS

Although left ventricular systolic functions were normal in all groups, there were statistically significant impairments of biventricular diastolic function parameters among renal transplant recipients compared with the control group.

Does the endothelial function change in renal transplant patients with longer duration of exposure and with higher cumulative doses of cyclosporine?

OBJECTIVE

Administration of cyclosporine (CsA) is one potential cause of endothelial dysfunction in renal transplant patients. We sought to investigate endothelial functional changes with respect to the cumulative dose and duration of exposure to CsA.

METHODS

Sixty-six renal recipients and 25 healthy controls were included in the study. The recipients were classified according to their time of CsA exposure: group 1 (0 to 36 months); group 2 (36 to 72 months); and group 3 (over 72 months). Endothelial function of the brachial artery was evaluated using high-resolution vascular ultrasound. Endothelium-dependent and -independent vasodilatation (EDD and EID, respectively) were assessed by assessing the responses to reactive hyperemia and using sublingual isosorbide dinitrate (ISDN), respectively.

RESULTS

There were no statistically significant differences between the groups with regard to their demographic, clinical, and most biochemical characteristics. Baseline measurements of the diameter of the brachial artery were similar in all groups. The values of mean brachial artery EDD and EID responses in groups 1, 2, and 3 were less than those in the control group (P < .05, P < .05, and P < .05, respectively). Mean brachial artery EDD and EID in group 1 were significantly impaired compared to groups 2 and 3 (for EDD: P < .05 and P < .05, respectively; for EID: P < .05 and P < .05, respectively). In contrast there was no difference between groups 2 and 3 with respect to these parameters. There were mild to moderate positive correlations between the cumulative doses of CsA and EDD and EID (r = .26 and r = .52, P < .05, respectively).

CONCLUSION

Endothelial dysfunction was more prominent in the first 36-month period than later despite the longer exposure to and higher cumulative doses of CsA. This finding may reflect an extended effect of the uremic state on endothelial function or more intense doses of CsA in early posttransplant period.

[Disorders of diastolic function in patients on hemodialysis]

INTRODUCTION

Impaired cardiac function is frequently present in patients on maintenance haemodialysis.

AIM

To assess the left ventricular diastolic function in patients on haemodialysis.

MATERIAL AND METHODS

We used 2D and pulsed wave Doppler echocardiography to evaluate the left ventricular diastolic function in 40 patients on haemodialysis and compared those to healthy controls.

RESULTS

Majority of Doppler parameters were changed in patients on haemodialysis. Diastolic dysfunction was present in 77.5% patients. In comparison to the healthy controls haemodialysis patients showed significant increase in peak velocity of late diastolic filling, (A wave, 76.82 +/- 23.76 cm/s vs. 58.46 +/- 9.65 cm/s p < 0.001) and reduction in the E/A ratio (1.00 +/- 0.26 vs. 1.26 +/- 0.31 p < 0.001).

CONCLUSION

There was significant impairment in left ventricular diastolic function in patients on haemodialysis.

Comparison of renal perfusion indices in captopril scintigraphy

Perfusion indices used in renal scintigraphy were adapted to captopril-enhanced renal scintigraphy in order to determine if these parameters have any value in differentiating patients with renovascular hypertension (RVH) from normal subjects. Regions of interest (ROIs) were chosen over the aorta and kidneys, and time-activity curves generated. The ratio of integrated aortic counts to renal counts, from the time of injection to arterial peak, was calculated. The difference in the value of this index between captopril and basal scintigraphies was -17 +/- 12 and -16 +/- 13 for the right and left kidneys, respectively, in the group of patients with essential hypertension, whereas in the patients with renovascular hypertension, these values were 24 in the stenotic and 14 in the non-stenotic kidney. This parameter is useful for separating patients with RVH from normal subjects.

The effects of slow-release verapamil on blood pressure and cardiovascular system in essential hypertension

The study consisted of 26 patients (15 female, 11 male; mean age 43 +/- 10 years) with mild to moderate essential hypertension (EH). They were followed for a 2-week washout period and then for another 2-week single-blind placebo phase. Four patients receiving placebo dropped out of the study. Patients qualified for active medication if their sitting diastolic blood pressures (BPs), the median of three readings, were between 95 and 115 mm Hg at the end of the placebo period. Slow-release verapamil 240 mg was given once or twice daily as the sole antihypertensive agent and was continued for 6 weeks. Two patients (9%) were excluded from the trial due to early side effects. A target diastolic BP of less than 90 mm Hg was obtained in the remaining 20 patients. At the end of the study, the mean value of sitting BP was reduced from an initial 170/103 (125) mm Hg to 130/81 (98) mm Hg (p less than 0.001) and the mean standing BP was decreased from 167/103 (125) mm Hg to 130/81 (98) mm Hg (p less than 0.001). The drug had no significant effects on the laboratory data, left ventricular performance as assessed by echocardiography and systolic time intervals, and the electrocardiogram parameters with the exception of PR prolongation (p less than 0.05). Adverse effects were noted in only three patients (14%). We conclude that slow-release verapamil is an effective, safe, and well-tolerated drug in treating EH.

Prognostic significance of isolated left anterior hemiblock and left axis deviation in the course of acute myocardial infarction

In 700 patients with acute myocardial infarction admitted to the intensive coronary care unit of our hospital, the incidence and significance of left anterior hemiblock and left axis deviation has been studied in the acute phase of disease. In 102 (14.6%) of the 700 patients, isolated left axis deviation (mean QRS axis-45 degrees) was found and 69 of them (9.9%) met the criteria of left anterior hemiblock. Of the 69 patients with left anterior hemiblock, 61 had acute anterior myocardial infarction, 5 had inferior infarction, and 3 had subendocardial infarction. The anterior hemiblock was transient in 5 patients, but persisted in 64. All patients with and without isolated left anterior hemiblock and left axis deviation were compared statistically with reference to mortality rate and the incidence of arrythmias; no significant difference was noted. However, in patients over the age of 65 and also in those with hypertension, the incidence of left axis deviation was significantly higher (P less than 0.05 and P less than 0.001, respectively). It was concluded that isolated left anterior hemiblock and left axis deviation occurring in the course of acute myocardial infarction no influence on the prognosis of acute myocardial infarction.