Dusanka Obradovic

Comorbidities and the risk of mortality in patients with bronchiectasis: an international multicentre cohort study.

BACKGROUND Patients with bronchiectasis often have concurrent comorbidities, but the nature, prevalence, and impact of these comorbidities on disease severity and outcome are poorly understood. We aimed to investigate comorbidities in patients with bronchiectasis and establish their prognostic value on disease severity and mortality rate. METHODS An international multicentre cohort analysis of outpatients with bronchiectasis from four European centres followed up for 5 years was done for score derivation. Eligible patients were those with bronchiectasis confirmed by high-resolution CT and a compatible clinical history. Comorbidity diagnoses were based on standardised definitions and were obtained from full review of paper and electronic medical records, prescriptions, and investigator definitions. Weibull parametric survival analysis was used to model the prediction of the 5 year mortality rate to construct the Bronchiectasis Aetiology Comorbidity Index (BACI). We tested the BACI as a predictor of outcomes and explored whether the BACI added further prognostic information when used alongside the Bronchiectasis Severity Index (BSI). The BACI was validated in two independent international cohorts from the UK and Serbia. FINDINGS Between June 1, 2006, and Nov 22, 2013, 1340 patients with bronchiectasis were screened and 986 patients were analysed. Patients had a median of four comorbidities (IQR 2-6; range 0-20). 13 comorbidities independently predicting mortality rate were integrated into the BACI. The overall hazard ratio for death conferred by a one-point increase in the BACI was 1·18 (95% CI 1·14-1·23; p<0·0001). The BACI predicted 5 year mortality rate, hospital admissions, exacerbations, and health-related quality of life across all BSI risk strata (p<0·0001 for mortality and hospital admissions, p=0·03 for exacerbations, p=0·0008 for quality of life). When used in conjunction with the BSI, the combined model was superior to either model alone (p=0·01 for combined vs BACI; p=0·008 for combined vs BSI). INTERPRETATION Multimorbidity is frequent in bronchiectasis and can negatively affect survival. The BACI complements the BSI in the assessment and prediction of mortality and disease outcomes in patients with bronchiectasis. FUNDING European Bronchiectasis Network (EMBARC).

Multidimensional severity assessment in bronchiectasis: an analysis of seven European cohorts

Introduction Bronchiectasis is a multidimensional disease associated with substantial morbidity and mortality. Two disease-specific clinical prediction tools have been developed, the Bronchiectasis Severity Index (BSI) and the FACED score, both of which stratify patients into severity risk categories to predict the probability of mortality. Methods We aimed to compare the predictive utility of BSI and FACED in assessing clinically relevant disease outcomes across seven European cohorts independent of their original validation studies. Results The combined cohorts totalled 1612. Pooled analysis showed that both scores had a good discriminatory predictive value for mortality (pooled area under the curve (AUC) 0.76, 95% CI 0.74 to 0.78 for both scores) with the BSI demonstrating a higher sensitivity (65% vs 28%) but lower specificity (70% vs 93%) compared with the FACED score. Calibration analysis suggested that the BSI performed consistently well across all cohorts, while FACED consistently overestimated mortality in ‘severe’ patients (pooled OR 0.33 (0.23 to 0.48), p<0.0001). The BSI accurately predicted hospitalisations (pooled AUC 0.82, 95% CI 0.78 to 0.84), exacerbations, quality of life (QoL) and respiratory symptoms across all risk categories. FACED had poor discrimination for hospital admissions (pooled AUC 0.65, 95% CI 0.63 to 0.67) with low sensitivity at 16% and did not consistently predict future risk of exacerbations, QoL or respiratory symptoms. No association was observed with FACED and 6 min walk distance (6MWD) or lung function decline. Conclusion The BSI accurately predicts mortality, hospital admissions, exacerbations, QoL, respiratory symptoms, 6MWD and lung function decline in bronchiectasis, providing a clinically relevant evaluation of disease severity.

Narrow Band Imaging Videobronchoscopy Improves Assessment of Lung Cancer Extension and Influences Therapeutic Strategy

OBJECTIVE Narrow band imaging (NBI) videobronchoscopy is a new technique aimed at lung cancer detection. This study investigated its sensitivity and specificity for evaluation of lung cancer extension and its possible influence on therapeutic decision, compared with white light videobronchoscopy. METHODS In this prospective study, we evaluated 106 patients with suspected lung cancer. All patients were examined using EVIS LUCERA videoendoscopy system. In every patient, at least three biopsies were taken from places visualized as pathologic, surrounding primary tumor, and three biopsies from places that appeared normal. The overall number of biopsies performed in 106 patients was 636. RESULTS The specificity and sensitivity of NBI in revealing greater lung cancer extension were 85.6% and 95%, respectively; positive and negative predictive values were 84% and 95.6%, respectively. Specificity and sensitivity were significantly better when compared with white light bronchoscopy alone (P < 0.01). NBI led to the change in therapeutic decision in 14 patients. There was statistically significant correlation between NBI assessment of tumor extension and change in therapeutic decision (P < 0.000). CONCLUSIONS NBI showed significantly better specificity and sensitivity in the assessment of lung cancer extension. NBI proved that it might have potential influence on therapeutic decision, making it more accurate. The procedure is safe and easily deployed in everyday practice.

Characterization of the “Frequent Exacerbator Phenotype” in Bronchiectasis

Rationale: Exacerbations are key events in the natural history of bronchiectasis, but clinical predictors and outcomes of patients with frequently exacerbating disease are not well described. Objectives: To establish if there is a “frequent exacerbator phenotype” in bronchiectasis and the impact of exacerbations on long‐term clinical outcomes. Methods: We studied patients with bronchiectasis enrolled from 10 clinical centers in Europe and Israel, with up to 5 years of follow‐up. Patients were categorized by baseline exacerbation frequency (zero, one, two, or three or more per year). The repeatability of exacerbation status was assessed, as well as the independent impact of exacerbation history on hospitalizations, quality of life, and mortality. Measurements and Main Results: A total of 2,572 patients were included. Frequent exacerbations were the strongest predictor of future exacerbation frequency, suggesting a consistent phenotype. The incident rate ratios for future exacerbations were 1.73 (95% confidence interval [CI], 1.47‐2.02; P < 0.0001) for one exacerbation per year, 3.14 (95% CI, 2.70‐3.66; P < 0.0001) for two exacerbations, and 5.97 (95% CI, 5.27‐6.78; P < 0.0001) for patients with three or more exacerbations per year at baseline. Additional independent predictors of future exacerbation frequency were Haemophilus influenzae and Pseudomonas aeruginosa infection, FEV1, radiological severity of disease, and coexisting chronic obstructive pulmonary disease. Patients with frequently exacerbating disease had worse quality of life and were more likely to be hospitalized during follow‐up. Mortality over up to 5 years of follow‐up increased with increasing exacerbation frequency. Conclusions: The frequent exacerbator phenotype in bronchiectasis is consistent over time and shows high disease severity, poor quality of life, and increased mortality during follow‐up.

The independent contribution of Pseudomonas aeruginosa infection to long-term clinical outcomes in bronchiectasis

Pseudomonas aeruginosa is responsible for chronic infection in many bronchiectasis patients but it is not known whether it is associated with worse clinical outcomes independent of the underlying severity of disease. This study analysed data from 2596 bronchiectasis patients included from 10 different bronchiectasis clinical centres across Europe and Israel, with a 5-year follow-up period. Prevalence of P. aeruginosa chronic infection and its independent impact on exacerbations, hospitalisations, quality of life and mortality was assessed. The prevalence of P. aeruginosa chronic infection was 15.0% (n=389). P. aeruginosa was associated with a higher mortality in a univariate analysis (hazard ratio (HR) 2.02; 95% (confidence interval) CI 1.53–2.66; p<0.0001) but an independent impact on mortality was not found in a multivariate analysis (HR 0.98; 95% CI 0.70–1.36; p=0.89). P. aeruginosa was independently associated with increased mortality only in patients with frequent exacerbations (two or more per year) (HR 2.03; 95% CI 1.36–3.03; p=0.001). An independent association with worse quality of life of 7.46 points (95% CI 2.93–12.00; p=0.001) was found in a multivariable linear regression. P. aeruginosa was therefore found to be independently associated with exacerbation frequency, hospital admissions and worse quality of life. Mortality was increased in patients with P. aeruginosa particularly in the presence of frequent exacerbations. Frequent exacerbations are the key determinants of long-term outcome in patients with chronic Pseudomonas aeruginosa infection http://ow.ly/WjPZ30h67rL

Standardised classification of the aetiology of bronchiectasis using an objective algorithm

Bronchiectasis (BE) is a chronic and progressive respiratory disease with multiple possible causes [1, 2]. Many require a specific therapy and thus, a systematic aetiologic evaluation is recommended by guidelines [3]. Studies have shown wide heterogeneity in the proportion of different aetiologies identified among centres [4–8], which can be partially justified because of geographical risks factors, but may also reflect variations in testing practice or in the definitions of aetiology used [9]. The proportion of patients classified as idiopathic varies (26–74%) across the literature, and this variability is likely to be somewhat linked to a lack of use of a standard aetiological algorithm [4–8]. The use of a standardised aetiological algorithm in bronchiectasis can improve the diagnosis of underlying cause http://ow.ly/5dga30gxrq3

Correlation between the Wells score and the Quanadli index in patients with pulmonary embolism

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).

Thrombophilia and thrombosis

INTRODUCTION Generally speaking, thrombophilia includes all congenital and acquired conditions associated with increased susceptibility to thrombosis. An impaired balance between stimulating and inhibitory components of the hemostasis system may result in thrombosis or hemorrhage (extreme disorders), while moderately impaired hemostasis induces thrombophilia. THROMBOPHILIA, PRETHROMBOTIC STATE AND THROMBOSIS A prethrombotic state is a condition of stimulated hemostasis system with tolerable intensity. When the activation level exceeds the capacity of inhibitory components, prethrombotic state advances to thrombosis. CLASSIFICATION OF THROMBOPHILIA Thrombophilia is classified as primary or hereditary and secondary or acquired. Hereditary or congenital thrombophilia is a condition of congenital mutation of one or more antithrombotic components. Acquired or secondary thrombophilia accompanies a variety of pathologic conditions and diseases. LABORATORY DIAGNOSIS OF THROMBOPHILIA Specific laboratory tests for congenital thrombophilia include assessment of the antigen component related to the activity of AT III, protein C, and protein S, evaluation of the resistance to the activated C protein, assessment of t-Pa and PAl-1 activity, as well as tests for hyperhomocysteinemia and prothrombin 20210 mutation. MANAGEMENT OF THROMBOPHILIA Treatment of patients with congenital AT III deficiency includes intravenous heparin and AT III concentrate (dosage 50 U/ kgbw). Patients with heterozygous protein C and S deficiency are treated by intravenous heparin and oral anticoagulant therapy. Regarding arterial thrombosis due to confirmed congenital hyperhomocysteinemia, it is treated the same as venous thrombosis.

Early predictors of NIV failure in AECOPD

Introduction: A question of how to recognize patients who may be safely ventilated outside ICU stands. Goals: To identify early predicotrs of NIV failure in AECOPD. Methods: 39-month prospective observational study at Vojvodina Institute for Pulmonary Diseases included 250 patients with AECOPD. We recorded: sex, age, earlier LTOT and NIV, Charlson, time from admission to NIV, initial pH, bicarbonates, PaCO2, PaO2, the changes in blood gas values after one hour, HR, RR, GCS, BT, BP, urine output, MEWS, consolidation on chest X-ray, tolerance, setting. Primary outcome was NIV failure defined as ETI or death. All variables were first tested with univariate analysis, and those with statistical significance with multivariate logistic regression. Results: NIV was successful in 164 patients (66%). There were 139(59%) male patients, and average age was 67. Patients with NIV failure had: higher Charlson(p=0.002, OR 1.29, 95%CI 1.10-1.51), consolidation in ≥2 quadrants (p=0.000, OR 5.38, 95%CI 2.48-11.65), longer time from admission to NIV(p=0.0034, OR 1.005, 95%CI 1.000-1.009), increased HR(p=0.031, OR 2.292, 95%CI 1.08-4.86), GCS≤11(p=0.042, OR 1.000, 95%CI 0.16-0.96), higher MEWS(p=0.000, OR 1.708, 95%CI 1.41-2.06), lower pH(p=0.004, OR 0.002, 95%CI 0.000-0.147), poorer tolerance (p=0.000, OR 2.102, 95%CI 0.145-0.339). Odds for NIV failure were twice as high on general wards (p=0.006, OR 2.102, 95%CI 1.236-3.574). Independent predictors were: Charlson(p=0.043, OR 1.246, 95%CI 1.007-1.541), MEWS(p=0.010, OR 1.394, 95%CI 1.083-1.795), pH(p=0.030, OR 0.642, 95%CI 0.430-0.958) and tolerance (p=0.000, OR 0.230, 95%CI 0.141-0.376). Conclusion: Patients with MEWS>4, Charlson>6, pH

First application of automated external defibrilator in Serbia: Case report

INTRODUCTION Sudden cardiac death is an unexpected natural death from cardiac causes. It is the most common and first manifestation of coronary artery disease. It accounts for 50% of mortality from cardiovascular disease in the United States of America and other developed countries, so measures that can reduce it are an important medical task. CASE REPORT A 55-year old man suddenly lost consciousness at the train station in Novi Sad. An eyewitness provided first aid and ventricular fibrillation was converted to sinus rhythm by means of the automated external defibrillator. Emergency Medical Service Novi Sad soon arrived, continued resuscitation procedure, and transported the patient to the Cardiac Care Unit, who was then diagnosed with acutedmyocardial infarction and primary percutaneous coronary intervention was performed. Resuscitative hypothermia was applied in acute phase to prevent further brain injury. During further hospitalization the patient was stable, woke up from coma and early rehabilitation measures were implemented. After six months the patient had normal physical activities and there was no left ventricular segmental hypokinesia on echo cardiography. CONCLUSION The application of all four chains of survival is important in increasing the survival rate of patients with sudden cardiac arrest.