Clinical Medicine Insights-Circulatory Respiratory and Pulmonary Medicine最新文献

Purpose: Right ventricular (RV) dysfunction in acute pulmonary embolism (PE) is a critical determinant of outcome. Obstructive sleep apnea (OSA) is a common comorbidity of PE and might also affect RV function. Therefore, we sought to investigate RV dysfunction in PE patients in proportion to the severity of OSA by evaluating the right-to-left ventricular (RV/LV) diameter ratio on computed tomographic pulmonary angiography (CTPA).

Materials and methods: 197 PE patients were evaluated for sleep-disordered breathing by portable monitoring and nocturnal polysomnography. RV dilatation was defined as an RV/LV diameter ratio of ⩾ 1.0.

Results: RV dilatation was significantly more frequent in OSA patients compared to study participants without OSA (66.4% vs 49.1%, P = .036). Elevated troponin I values, indicating myocardial injury due to acute, PE-related RV strain, were significantly more frequent in OSA patients with an apnea-hypopnea index (AHI) ⩾ 15/h compared to those with an AHI < 15/h (62.1% vs 45.8%, P = .035). However, RV dysfunction documented by the RV/LV diameter ratio on CTPA was not significantly associated with the severity of OSA in multivariable regression analysis.

Conclusion: Patients with moderate or severe OSA might compensate acute, PE-related RV strain better, as they are adapted to repetitive right heart pressure overloads during sleep.

Hyperammonemia is the pathological accumulation of ammonia in the blood, which can occur in many different clinical settings. Most commonly in adults, hyperammonemia occurs secondary to hepatic dysfunction; however, it is also known to be associated with other pathologies, surgeries, and medications. Although less common, hyperammonemia has been described as a rare, but consistent complication of solid organ transplantation. Lung transplantation is increasingly recognized as a unique risk factor for the development of this condition, which can pose grave health risks-including long-term neurological sequelae and even death. Recent clinical findings have suggested that patients receiving lung transplantations may experience postoperative hyperammonemia at rates as high as 4.1%. A wide array of etiologies has been attributed to this condition. A growing number of case studies and investigations suggest disseminated opportunistic infection with Ureaplasma or Mycoplasma species may drive this metabolic disturbance in lung transplant recipients. Regardless of the etiology, hyperammonemia presents a severe clinical problem with reported mortality rates as high as 75%. Typical treatment regimens are multimodal and focus on 3 main avenues of management: (1) the reduction of impact on the brain through the use of neuroprotective medications and decreasing cerebral edema, (2) augmentation of mechanisms for the elimination of ammonia from the blood via hemodialysis, and (3) the diminishment of processes producing predominantly using antibiotics. The aim of this review is to detail the pathophysiology of hyperammonemia in the setting of orthotopic lung transplantation and discuss methods of identifying and managing patients with this condition.

Background: Thoracoscopy allows visualization of the pleural cavity including diaphragm, visceral pleura, and lungs. It provides the physician with information about the disease extent and it has the ability to get a biopsy from these lesions to differentiate between tumors and fibrotic reactions. This study aims to compare minithoracoscopy and medical thoracoscope in patients with exudative pleural effusion as regards the diagnostic yield, safety, complications, and duration of hospital stay.

Patients and methods: Sixty patients were diagnosed with exudative pleural effusion and were randomly divided into 2 equal groups: Group (1): included 30 patients who underwent minithoracoscopy and Group (2): included the remaining 30 cases who underwent the standard thoracoscope.

Results: Pathological examination of the sample revealed that biopsy size was 2.02 and 1.25 in group 1 and group 2 was respectively with highly statistically significant between both groups (P < .001). Group 1 revealed TB, malignant, chronic nonspecific pleurisy, Staph aureus, Klebsiella, and Pseudomonas in 30% (9), 30% (9), 33.3% (10), 69% (9), 15% (2), and 15% (2) of cases respectively. While group 2 reveled TB, malignancy, chronic nonspecific pleurisy, Staph aureus, Klebsiella, Pseudomonas, and other causes in 40% (12), 23.3% (7), 23.3% (7), 67% (8), 8% (1), 8% (1), and 16% (2) respectively with no statistically significant differences between both groups (P > .05).

Conclusion: Minithoracoscopy is well tolerated by patients as minimal pain and early hospital discharge could be achieved by that approach.

The COVID-19 pandemic has presented challenges in symptomology identification, diagnosis, management and follow-up in common respiratory diseases, and in particular asthma. Research is rapidly ongoing to try and understand how the SARS-CoV-2 virus affects individuals with asthma, as well as, how underlying asthma affects Covid-19 risk, symptomology and prognosis. In light of this unique medical challenge, clinicians are faced with case-by-case based decisions to implement or continue current asthma therapy. This review will discuss the current literature regarding asthma and COVID-19 based on best available evidence at this time (See box 1).

Importance: Coronavirus 2019 pandemic (COVID 19) is caused by the Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) virus. The pandemic is affecting the livelihood of millions of people all over the world. At the time of preparing this report, the pandemic has affected 1 827 284 patients, with 113 031 deaths in 185 countries as per Johns Hopkins University. With no proven treatment for the disease, prevention of the disease in the community and healthcare setting is need of the hour.

Objective: To perform a comprehensive literature search for preventive measures and experimental treatment options. In this review, we have focused our discussion on the risk of disease transmission, supportive treatment, and possible treatment options based on available evidence.

Evidence review: We performed a literature search on google scholar, PubMed, and society guidelines for literature related to COVID 19 and previous coronavirus pandemics. We included data review articles, observational studies, and controlled trials to synthesize the treatment options for COVID 19.

Findings: In this article, we have extensively reviewed and discussed recommendations from various world organizations for the public and healthcare workers. We have also discussed currently available experimental treatments since there is no proven treatment for COVID 19. The best method of dealing with the current outbreak is to reduce the community spread and thus "flatten the curve." Although Hydroxychloroquine, Remdesivir, Lopinavir/Ritonavir, and Azithromycin have been tried, passive immunity through convalescent serum and vaccine is still at an experimental stage. Patients with severe COVID 19 infections could be considered for this experimental treatment through various national randomized control trials, which may eventually lead to an evidence-based treatment strategy.

Conclusions and relevance: Awareness of currently available experimental treatment among healthcare providers and exploration of possible treatment options through evidence is need of the hour. We have discussed the most recently available literature and evidence behind experimental treatment in this article.

Background: Pressures measured during mechanical ventilation provide important information about the respiratory system mechanics and can help predict outcomes.

Methods: The electronic medical records of patients hospitalized between 2010 and 2016 with sepsis who required mechanical ventilation were reviewed to collect demographic information, clinical information, management requirements, and outcomes, such as mortality, ICU length of stay, and hospital length of stay. Mechanical ventilation pressures were recorded on the second full day of hospitalization.

Results: This study included 312 adult patients. The mean age is 59.1 ± 16.3 years; 57.4% were men. The mean BMI was 29.3 ± 10.7. Some patients had pulmonary infections (46.2%), and some patients had extrapulmonary infections (34.9%). The overall mortality was 42.6%. In a multi-variable model that included age, gender, number of comorbidities, APACHE 2 score, and PaO₂/FiO₂ ratio, peak pressure, plateau pressure, driving pressure, and PEEP all predicted mortality when entered into the model separately. There was an increase in peak pressure, plateau pressure, and driving pressure across BMI categories ranging from underweight to obese.

Conclusions: This study demonstrates that ventilator pressure measurements made early during the management of patients with acute respiratory failure requiring mechanical ventilation provide prognostic information regarding outcomes, including mortality. Patients with high mechanical ventilator pressures during the early course of their acute respiratory failure require more attention to identify reversible disease processes when possible. In addition, increased BMIs are associated with increased ventilator pressures, and this increases the complexity of the clinical evaluation in the management of obese patients.

Background: There is a dearth of publications on the prevalence of venous thromboembolism in Ghana. Knowledge of the prevalence of venous thromboembolism, which is often undetected clinically, will help save lives as appropriate interventions can be made as well as provide a general clue to clinicians on detecting venous thromboembolism and pulmonary embolism.

Methods: The study employs a retrospective design with data extracted from the Autopsy Daybook of the Pathology unit, Komfo Anokye Teaching Hospital, 2009 to 2016. Data on patients' demographics were retrieved to establish diagnoses and age and gender distribution. Analysis was made of pulmonary embolism and deep vein thrombosis as a cause of death recorded on death certificates using the criteria of the International Classification of Diseases, version 10.

Results: A total of 150 cases of deep vein thrombosis and/or pulmonary embolism were available for the study period and the results showed an average age of 45.3 years with a standard deviation of 19.96. The ages ranged between 3 years and 96 years with the age group 31 to 40 years being the modal age group. Males recorded the highest number of cases with 92 (59.35%) compared to females with 63 (40.65%). Respiratory disorders, of which pneumonia is the most prevalent, are the leading clinical condition that is often misdiagnosed in place of pulmonary thromboembolism.

Conclusion: VTE is a major health problem especially among the elderly, but unfortunately the clinical diagnosis is usually missed by clinicians hence the need to maintain a high suspicion index.

Solitary fibrous tumors of the pleura (SFTP) are rare mesenchymal neoplasms that originate from mesenchymal growth in the pleura, tend to be single tumors, usually have an indolent course and show nonspecific symptoms. SFTP can be often diagnosed from an incidental finding of a single mass in the thorax and should be confirmed by biopsy and immunohistochemistry. A minority of cases may present Doege-Potter syndrome (DPS, episodes of refractory hypoglycemia) associated with production of insulin-like growth factor 2 (IGF-2). Both SFTP and DPS are rare occurrences with less than 2000 cases reported worldwide. The curative treatment is tumor resection. Two cases of patients with DPS caused by SFTP are presented below.

Background: N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiopulmonary exercise testing (CPET) are useful for severity assessment in patients with pulmonary hypertension (PH). Correlations between these tests in pre-capillary PH patients is less well studied.

Methods: We studied 23 patients with pre-capillary PH: 8 with idiopathic pulmonary arterial hypertension (IPAH), 6 with systemic sclerosis-associated PAH (SSc-PAH), and 9 with chronic thromboembolic pulmonary hypertension (CTEPH). Clinical evaluation, NT-proBNP levels, six-minute walking test (6MWT), spirometry, and CPET were evaluated on the same day. Correlation between NT-proBNP levels and CPET parameters were investigated.

Results: In all patients, NT-proBNP levels were significantly correlated with peak oxygen uptake (VO₂) (r = -0.47), peak oxygen pulse (r = -0.43), peak cardiac output (CO) (r = -0.57), peak end-tidal partial pressure of carbon dioxide (P_ETCO₂) (r = -0.74), ventilatory equivalent to carbon dioxide (VE/VCO₂) at anaerobic threshold (AT) (r = 0.73), and VE/VCO₂ slope (r = 0.64). Significant correlations between NT-proBNP levels and peak P_ETCO₂ and VE/VCO₂ were found in IPAH and CTEPH subgroups, and a significant correlation between NT-proBNP levels and VO₂ at AT was found in the CTEPH subgroup. No significant correlation was found in the SSc-PAH subgroup.

Conclusion: NT-proBNP levels were significantly correlated with CPET parameters in patients with IPAH and CTEPH subgroups, but not in SSc-PAH subgroup. A further study with larger population is required to confirm these preliminary findings.

Background: Acute pulmonary embolism (PE) is the third most fatal cardiovascular disease. PE is frequently misdiagnosed due to its clinical presentation's heterogeneity and the inexistence of biomarkers for its immediate diagnosis. Mean platelet volume (MPV) has shown a potential role as a biomarker in acute PE. In this analysis, we aimed to systematically compare the MPV in patients with and without definite diagnosis of PE, in emergency departments.

Methods: Embase, PubMed and Medline were searched for relevant publications, in English. The main inclusion criteria were studies which compared MPV in patients with acute PEA versus a control group.

Results: Thirteen studies consisting of a total number of 2428 participants were included. Of the participants included, 1316 were patients with confirmed acute PE, and 1112 were assigned to the control group. MPV was significantly higher in patients with acute PE than in controls (RR: 0.84, 95% CI: 0.76 - 0.92; P < .00001). There was a significant heterogeneity in the data.

Conclusions: This analysis showed higher MPV to be associated with acute PE immediate diagnosis. These data show promise for the use of MPV as a readily available biomarker for the diagnosis of acute PE at the emergency department.