Introduction. Diagnostic and therapeutic algorithms for pulmonary embolism (PE) have been frequently modified; however, determining clinical probability, which dictates further procedures, has ...remained the first step. The objective was to illustrate therapeutic dilemma in a patient with intermediate high risk for 30-day mortality. Case outline. The patient was a 56-years-old woman who was referred to our institution for suspected PE. According to the Wells score, the patient was deemed as low-probability for venous thromboembolism, and after further stratification she was placed in a group with intermediate high risk for 30-day mortality. PE was confirmed by computerised tomography pulmonary angiography and she initially received heparin. During the further clinical course, she developed hemodynamic instability, and she received thrombolytic therapy, with a positive outcome. The patient also had increased lactate at admission ? marker of tissue hypoperfusion which is not a part of the routine laboratory work-up in PE patients. Conclusion. Current guidelines state that patients with intermediate high risk for 30-day mortality should be treated with heparin, and then continuously monitored in order to timely recognize potential hemodynamic instability and consequently apply thrombolytics. In the outlined case, thrombolytic therapy was applied only after the patient developed hemodynamic instability, although previously she had early signs of tissue hypoperfusion.
nema
Introduction/Objective. Population of elderly people is increasing and modern medicine is faced with the problem of large morbidity and mortality from cardiovascular diseases in this age group. ...Modern treatment strategies have not been sufficiently investigated in the elderly, therefore these people often receive suboptimal treatment. The aim of the study was to evaluate clinical characteristic, cardiac risk factors, management strategies and early outcome in the elderly patient with ST elevated myocardial infarction (STEMI). Methods. This retrospective study included 217 consecutive patients, aged ? 70 years (mean age 77.6 ? 4.9 years, 103 men, 114 women) with STEMI admitted to the Institute of Cardiovascular Diseases of Vojvodina. We have analyzed patients? clinical characteristics, risk factors, left ventricular function and treatment strategies in relation to in-hospital outcome. Results. First clinical symptom was chest pain in 209 (96.3%) of patients. On admission, 35 (16.1%) patients were with severe signs of heart failure (Killip class III?IV). Duration of symptom onset to hospital admission was 14.7 ? 28.6 hours. Out of 217 patients, 168 (77.4%) patients received reperfusion treatment, including primary percutaneous coronary ntervention (PPCI) in 164 (75.6%) patients, and fibrinolytic therapy in 4 (1.8%) patients. Hospital mortality was 26.3% (57 patients). PPCI was univariate predictor of lower in-hospital mortality, whereas multivariate predictors of in-hospital mortality were cardiogenic shock (OR 67.095; 95% CI (6.845?657.646); p < 0.001) and low ejection fraction (OR 0.901; 95% CI (0.853?0.963); p = 0.001). Conclusion. In elederly patients presenting with STEMI, PPCI was asscoiated with lower mortality, whereas cardiogenic shock and lower ejection fraction were independent predictors of worse prognosis after STEMI.
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Background and Aims
Determining clinical probability of pulmonary embolism (PE) with Wells scoring system is the first step towards diagnosis of PE. Definitive diagnosis of PE is confirmed by ...computed tomography pulmonary angiography (CTPA).
Methods
This was a prospective study on 80 patients referred to the Institute for Pulmonary Diseases of Vojvodina with suspected PE between April 2010 and August 2012. Clinical probability of PE was determined according to the Wells and modified Wells scoring system. CTPA was performed in 60 patients. The degree of pulmonary vascular obstruction was quantified by the Qanadli index.
Results
Low clinical probability of PE was present in one patient (1.6%), moderate in 43 (71.6%) and high in 16 (26.6%) patients. PE was confirmed in 50 (83.3%) patients. There were 21 patients (42%) whose Quanadli index was <25%, 18 (36%) between 25%–50%, while Quanadli index was ≥50 in 11 patients (22%). When compared to CTPA findings, modified Wells scoring system showed 90% sensitivity 95% confidence interval (CI) 78.2%–96.6%, and 20% specificity (95% CI 3.11%–55.6%), positive predictive value (PPV) 84.9% (95% CI 72.4%–93.2%) and negative predictive value (NPV) 28.6% (95% CI 4.5%–70.7%). There was weak positive correlation between Wells score and Quanadli index (r = 0.14; P = 0.29), without statistical significance. Wells score was significantly higher in haemodynamically unstable than in haemodynamically stable patients (6.8 vs 5.6, P = 0.014). There was no statistically significant difference between the values of Quanadli index in these two groups (31.33% vs 26.64%, P = 0.062).
Conclusion
Modified Wells criteria have high sensitivity but low specificity in PE diagnostics. The Wells score does not correlate well with the Quanadli index.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Shortage of intensive care beds has led to more frequent use of noninvasive ventilation (NIV) outside respiratory units, and data on NIV efficacy and safety on general wards is lacking.
The aim was ...to identify potential predictors for NIV failure.
This was a retrospective analysis of patients treated with NIV at the Institute for Pulmonary Diseases of Vojvodina from 2009 to 2013. Demographics, blood gases, chest radiographs, setting, and outcomes were analyzed to identify predictors of NIV failure.
A total of 138 patients (65% men, mean age 66 ± 11 years) were treated with NIV. Indications for NIV were acute exacerbation of chronic obstructive pulmonary disease (85%) and cardiogenic pulmonary edema (7%), as well as respiratory insufficiency related to obesity and central hypoventilation (5%) and neuromuscular disease (3%). Rate of NIV failure was 34.8%. In 86 patients NIV was applied in the High Dependency Unit (HDU), while 52 received NIV on the general ward. Baseline characteristics in terms of gender, arterial blood gases, and the extent of consolidation on chest radiographs were similar. Patients treated in HDU were younger (64.4 ± 1.2 vs. 69.4 ± 1.5 years, p < 0.001). NIV on the general ward compared to HDU had higher rates of NIV failure (28/52 vs. 20/86, p < 0.001). Presence of consolidation involving two or more quadrants on chest radiograph (55% vs. 29%, p < 0.001) was associated with NIV failure. When adjusted for age and the extent of consolidation on chest radiograph, NIV failure was still less likely in patients treated in HDU (OR 0.23, 95% Cl 0.10-0.50).
Patients with consolidation on chest X-ray and patients treated with NIV outside of dedicated respiratory units are at a higher risk for NIV failure.
The diagnosis of sarcoidosis-associated pulmonary hypertension is a challenge, because there are signs and symptoms, such as dyspnea, dizziness, and chest pain that are nonspecific and may exist in ...both diseases. Right heart catheterization is the gold standard for the diagnosis of pulmonary hypertension. However, this is an invasive procedure, so it is reserved for patients with a high probability of the presence of pulmonary hypertension. Current guidelines for the diagnosis of pulmonary hypertension recommend transthoracic echocardiography for the screening method. Adequate treatment of underlying diseases and comorbidities is important in order to prevent disease progression, disability, and shortened patient survival. Specific therapy for SAPH is not routinely recommended.
Influenza A (H1N1) re-emerged in the human population during 2009. The aim of this study was to describe characteristics, laboratory findings, clinical presentation and treatment outcome among ...patients with influenza A (H1N1) infection.
The study was performed at the Institute for Pulmonary Diseases of Vojvodina including all the patients hospitalized at the Intensive Care Unit or High Dependency Unit with confirmed, probable or suspected Influenza A (H1N1) infection between November 6th, 2009 and April 13th, 2010.
Among 64 patients Influenza A (H1N1) infection was confirmed by rt-PCR in 50, defined as probable in 7 and as suspected in 6 patients. There was an equal number of male and female patients. Their mean age was 46 years (SD +/- 12.1). None of the patients were vaccinated against influenza. Comorbidities were present in 37 (58%) patients. There were 29 (45%) obese patients. Three patients were pregnant. The median time from symptom onset to hospital admission was 5 days (IQR 4-7). At admission, the median Modified Early Warning Score (MEWS) was 4 (IQR 3-6). The most common presenting symptoms were cough (100%) and fever (89%). The mean oxygen saturation at admission was 85.3% (SD 9.0). Auscultatory finding of wheesing in the absence of a chronic lung disease was found in 10 (15.6%) patients. Leukopenia was noted in 23 (35.9%) patients, and thrombocytopenia in 14 (21.9%) patients. Aspartate aminotransferase values were elevated in 41 (64.1%) patients, alanine aminotransferase in 32 (50%) patients, and creatine kinase in 36 (56.2%) patients. Opacities on an initial chest radiograph were predominantly patchy and the median number of the lung fields involved was 1 (IQR = 0-3). The non-survivors had statistically significantly higher MEWS at admission (p = 0.0001), lower oxygen saturation (p = 0.001), more lung fields involved on an initial chest radiograph (p = 0.006), wheezing in the absence of chronic lung disease (p = 0.02) and elevated aspartat aminotransferase (p = 0.02) and creatine kinase (p = 0.03). Acute respiratory disstress developed in 21 (32.9%) patients, and mechanical ventilation was required in 23 (36.1%) patients. Septic shock developed in 12 (18.7%) patients, and 19 (29.7%) patients had a multi-organ dysfunction. The overall hospital mortality was high--20.3% (95% CI, 11.3%-32.2%; n = 13), and especially so among the patients who required mechanical ventilation--56.5% (95% CI, 36.8%-74.40%).
Timely initiation of antiviral therapy and early recognition of critically ill are important factors for reducing mortality.
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DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Abstract
Background and Aims
Determining clinical probability of pulmonary embolism (
PE
) with
W
ells scoring system is the first step towards diagnosis of
PE
. Definitive diagnosis of
PE
is ...confirmed by computed tomography pulmonary angiography (
CTPA
).
Methods
This was a prospective study on 80 patients referred to the
I
nstitute for
P
ulmonary
D
iseases of
V
ojvodina with suspected
PE
between
A
pril 2010 and
A
ugust 2012. Clinical probability of
PE
was determined according to the
W
ells and modified
W
ells scoring system.
CTPA
was performed in 60 patients. The degree of pulmonary vascular obstruction was quantified by the
Q
anadli index.
Results
Low clinical probability of
PE
was present in one patient (1.6%), moderate in 43 (71.6%) and high in 16 (26.6%) patients.
PE
was confirmed in 50 (83.3%) patients. There were 21 patients (42%) whose
Q
uanadli index was <25%, 18 (36%) between 25%–50%, while
Q
uanadli index was ≥50 in 11 patients (22%). When compared to
CTPA
findings, modified
W
ells scoring system showed 90% sensitivity 95% confidence interval (
CI
) 78.2%–96.6%, and 20% specificity (95%
CI
3.11%–55.6%), positive predictive value (PPV) 84.9% (95%
CI
72.4%–93.2%) and negative predictive value (NPV) 28.6% (95%
CI
4.5%–70.7%). There was weak positive correlation between
W
ells score and
Q
uanadli index (r = 0.14;
P
= 0.29), without statistical significance.
W
ells score was significantly higher in haemodynamically unstable than in haemodynamically stable patients (6.8 vs 5.6,
P
= 0.014
).
There was no statistically significant difference between the values of
Q
uanadli index in these two groups (31.33% vs 26.64%,
P
= 0.062).
Conclusion
Modified
W
ells criteria have high sensitivity but low specificity in
PE
diagnostics. The
W
ells score does not correlate well with the
Q
uanadli index.
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FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
Wegener's granulomatosis usually presents with clinical features of systemic vasculitis affecting lung, upper respiratory tract, kidney and even a nervous system. Yet, invasive pulmonary ...aspergillosis is characterised by invasion of blood vessels in the lungs, but the infection often spreads to kidneys, skin and central nervous system. We report a case of a 46-year-old male patient with no prior medical history. Clinical presentation included epistaxis, hemoptysis, hematuria and proteinuria, along with pulmonary nodular infiltrates. Differential diagnosis included invasive aspergillosis and Wegener's granulomatosis, but the diagnosis was only confirmed after autopsy. Establishing diagnosis of invasive aspergillosis remains a challenge for clinicians in acute care setting.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Rett syndrome (RTT) is a severe neurodevelopmental disorder that represents the second most common cause of mental retardation in females. However, incidence and prevalence of RTT are scarcely ...reported.
A retrospective study included all patients with RTT diagnosed between 1981 and 2012 in Serbia. Estimation of incidence and prevalence was calculated on the basis of vital statistics reported by Statistical Office of Republic of Serbia.
From 1981 to 2012, RTT has been diagnosed in 102 girls in Serbia. Incidence of RTT in Serbia is estimated at 0.586:10,000 female live births. We estimated the prevalence of RTT in population of females younger than 19 years at 1:8,439. Death occurred in 19 patients (18.63%), with pneumonia as the most common cause. The lethal outcome by the age of 12 years could be expected for 11% of patients. The mean age at diagnosis was 3.5 years and we have confirmed a significant trend towards earlier dianosis during studied period.
Rett syndrome incidence in Serbia is in accordance with reports from other countries. Serbian RTT patients have increased risk for early death when compared to patients in more developed countries, most commonly due to pneumonia. There was significant trend towards early diagnosis of RTT in Serbia over recent decades.
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