Marina Petrovic

Community-acquired pneumonia: economics of inpatient medical care vis-à-vis clinical severity,

Objective: To assess the direct and indirect costs of diagnosing and treating community-acquired pneumonia (CAP), correlating those costs with CAP severity at diagnosis and identifying the major cost drivers. Methods: This was a prospective cost analysis study using bottom-up costing. Clinical severity and mortality risk were assessed with the pneumonia severity index (PSI) and the mental Confusion-Urea-Respiratory rate-Blood pressure-age ≥ 65 years (CURB-65) scale, respectively. The sample comprised 95 inpatients hospitalized for newly diagnosed CAP. The analysis was run from a societal perspective with a time horizon of one year. Results: Expressed as mean ± standard deviation, in Euros, the direct and indirect medical costs per CAP patient were 696 ± 531 and 410 ± 283, respectively, the total per-patient cost therefore being 1,106 ± 657. The combined budget impact of our patient cohort, in Euros, was 105,087 (66,109 and 38,979 in direct and indirect costs, respectively). The major cost drivers, in descending order, were the opportunity cost (lost productivity); diagnosis and treatment of comorbidities; and administration of medications, oxygen, and blood derivatives. The CURB-65 and PSI scores both correlated with the indirect costs of CAP treatment. The PSI score correlated positively with the overall frequency of use of health care services. Neither score showed any clear relationship with the direct costs of CAP treatment. Conclusions: Clinical severity at admission appears to be unrelated to the costs of CAP treatment. This is mostly attributable to unwarranted hospital admission (or unnecessarily long hospital stays) in cases of mild pneumonia, as well as to over-prescription of antibiotics. Authorities should strive to improve adherence to guidelines and promote cost-effective prescribing practices among physicians in southeastern Europe.

NT-proBNP for prognostic and diagnostic evaluation in patients with acute coronary syndromes

BACKGROUND AND AIM N terminal-proB-type natriuretic peptide (NT-proBNP) is synthesised and secreted from the ventricular myocardium. This marker is known to be elevated in patients with acute coronary syndromes (ACS). We evaluated NT-proBNP asa significant diagnostic marker and an important independent predictor of short-term mortality (one month) in patients with ACS. METHODS NT-proBNP and cardiac troponin I (cTI) were assessed in 134 consecutive patients (median age 66 years, 73% male)hospitalised for ACS in a cardiological university department. The patients were classified into ST-elevation ACS (STE-ACS, n = 74) and non-ST-elevation ACS (NSTE-ACS, n = 60) groups based on the ECG findings on admission. Patients with Killip class ≥ II were excluded. RESULTS The serum level of NT-proBNP on admission was significantly higher (p < 0.0005), while there was no difference in cTI serum level in the NSTE-ACS patients compared to STE-ACS patients. There was a significant positive correlation between NT-proBNP and cTI in the NSTE-ACS (r = 0.338, p = 0.008) and STE-ACS (r = 0.441, p < 0.0005) patients. There was a significant difference in NT-proBNP (p < 0.0005) and cTI (p < 0.0005) serum level between ACS patients who died within 30 days or who survived after one month. The increased NT-proBNP level is the strongest predictor of mortality in ACS patients, also NT-proBNP cut-point level of 1,490 pg/mL is a significant independent predictor of mortality. CONCLUSIONS We demonstrated the differences and the correlation in the secretion of NT-proBNP and cTI in patients with STE-ACS vs. NSTE-ACS. Our results provide evidence that NT-proBNP is a significant diagnostic marker and an important independent predictor of short-term mortality in patients with ACS.

Neuroendocrine Markers-Useful Predictors of Therapeutic Responses in Non-resectable Non-small Cell Lung Cancer

Objective: This study correlates the neuroendocrine (NE) markers neuron-specific enolase (NSE), chromogranin A (CGA), and synaptophysin (SYN) with the therapeutic responses and the survival times of patients with non-resectable non-small cell lung cancer (NSCLC). Method: One hundred twenty-six patients (male 64%, female 36%) with histopathologically confirmed NSCLC, treated with combination chemotherapy and radiotherapy in 1 center, underwent immunohistochemical analyses. Results: Thirty-nine patients (31%) were positive for NSE, 24 (19%) for Chr A, and 27 (21%) for SYN. Favorable therapeutic responses (partial and complete responses [CR]) were significantly greater in patients expressing NSE, Chr A, and SYN (P<0.05). There was a significant correlation between the therapeutic response and the percentage of NE-positive tumor cells (P<0.05). Tumors with greater than 25.5% NSE-positive cells can be predicted to have a favorable therapeutic response (94% sensitivity, 100% specificity). Patients with multiple markers were also more likely to have a favorable response compared to those with only 1 marker (59% compared with 38%) (P<0.05). Those with positive NE expression had significantly better 1- and 2-year survival compared with non-expressers (60% compared with 18%, P<0.001, and 33% compared with 0% P=0.000, respectively). Conclusion: Patients expressing the NE markers NSE, Chr A, and SYN, and those with a larger proportion of positive tumor cells have better therapeutic responses and longer survival times.

[Non allergic simple eosinophilic pneumonia--Löffler syndrome--a case report study].

INTRODUCTION Löffler syndrome is an acute, pneumonia of unknown ethiology. This disease is not often associated with bronchial asthma. In its asymptomatic form, this disease is reversible, transient, self-limited with no requests for specific therapy regimen. In the symptomatic form, as well as during its progression, treatment with steroids is very effective. Furthermore, in both acute eosinophilic and idiopathic chronic eosinophilic form, this kind of therapy ensures survival. CASE REPORT The case of a 53-year-old Caucasian woman was presented with 2-month history of low grade fever, shortness of breath, cough and reduced exercise tolerance. Although she had an allergic accident on insects in history, non allergy reactions as well as an obstructive disease with that kind of origin were not detected on admission. The diagnosis of simple eosinophilic pneumonia (SEP) (Löfflers syndrome) was confirmed by transbronchial biopsy and by sternal testing. The peripheral blood eosinophilia with pulmonary eosinophilic infiltrates on X ray chest radiography were observed during clinical examination. Biopsy specimen of the lung parenchym showed changes associated with Löfflers syndrome. The diagnosis was, also, confirmed according to the radiographic findings of unilateral migratory infiltrates consistent pneumonia. DISCUSSION Churg Strauss syndrome (CSS) has to be considered in this differential diagnosis. Frequently, this disease has extrinsic bronchial asthma with eosinophilic pneumonia in history: asthma is often associated with allergic bronchopulmonary aspergillosis. In the reported case, treatment with steroids resulted in a marked clinical improvement compared to nonsteroid therapy.

Difficulties in diagnosis of tuberculosis without bacteriologic confirmation in a 15-year-old boy from contact with a patient with tuberculosis: A case report

Introduction. After the contact with a patient suffering from tuberculosis (TB), previously healthy children have 1%–16% possibility to develop the disease. TB diagnosis in children is not easy to confirm so 15%–25% of cases remain undiagnosed. Case report. A 15-yearold-boy was hospitalized with productive cough, pain in the right flank area, fever, and fatigue, loss of appetite and night sweats. One of the boys uncles was cured of tuberculosis, another uncle had active tuberculosis and both of them were in contact with the boy, but they did not live in the same household. During the physical examination, the child was febrile, with dyspnea, pale, with profuse sweating, debilitate. BCG (Bacillus Calmette – Guérin) scar was present. The auscultatory findings of the lungs showed quiet breathing from the scapula to the right lung base and chest radiography suggested massive right sided pleuropneumonia. The parameters of the inflammation were high and Mycobacterium tuberculosis (MTB) was not found in the samples of sputum and gastric lavage. Pleural puncture revealed exudative nature in the aspirated fragment. Cytology was nonspecific, the MTB was not found and the planted surfaces on Lowenstein-Jensen remained sterile. Tuberculin skin test (TST) – Mantoux was positive (+ 10 mm), Interferon Gamma Release Assay (QuantiFERON-TB GOLD In-Tube) was negative. The boy was unsuccessfully treated with broad spectrum antibiotics. By video-assisted thoracoscopy, the pleural tissue clip confirmed the benign chronic granulomatous process, while histochemical staining did not show MTB. The treatment with anti-TB medication led to clinical and radiographic recovery. The boy is now in good general condition, without consequences of the disease. Conclusion. This case report pointed out the importance of risk factors and difficulties in diagnosing TB in children.

Primary Small Cell Carcinoma Of Lung With Metachronous Breast Metastasis

Abstract Breast metastases from an extra-mammary malignancy are rare. Among the lung malignancies that metastasise in the breasts, previous literature has described approximately 30 cases of NSCLC and only a few cases of SCLC. Here, we present a 54-year-old woman with metachronous breast metastasis from pulmonary small cell carcinoma. She presented with a soft tissue mass in the right lung hilum. After bronchoscopy with biopsy, SCLC was verified. Th e patient was given 4 cycles of etoposide and cisplatin followed by radiation therapy. Seven months after the diagnosis of primary lung cancer, the patient palpated a mass in her right breast. Clinical examination and further diagnostics revealed the suspected malignancy, and a radical mastectomy was performed. Immunohistochemical findings suggested metastatic SCLC in the breast. Differentiation between primary and metastatic cancer in the breast is very important for therapeutic planning

Churg-Strauss vasculitis in patient who received montelukast

Introduction. Montelukast is a selective leukotriene receptor antagonist. One of side effects of this drug class is the ChurgStrauss syndrome (CSS). There is still no reliable evidence whether the expression of this syndrome could be masked by high doses of corticosteroids and become expressed by termination of corticosteroid use, or whether it could be a consequence of leukotriene receptor antagonists use. Case report. Female patient, aged 49 years, was hospitalized with symptoms of fever, dyspnea, cough and increased sputum production with occasional hemoptysis. She was treated for asthma during the previous year. Leukocyte differential formula registered 44% of eosinophils. IgE value was extremely elevated, with value measured to 580 kU/L and eosinophile cation protein value was 15.1 μg/L. Computed tomography of the chest described changes in the form of ground glass located in all lobes of the right lung and in the upper lobe of the left lung. Computed tomography of paranasal sinuses described changes that could resemble to polyposis, chronic sinusitis, and possible granulomatosis. Mononeuritis of peroneal nerve of the right leg was proven by electromyographic examination. Bone marrow biopsy indicated hypercellularity with domination of eosinophilic granulocytes (30%). Five out of six criteria were noted in patient’s clinical presentation, after which the diagnosis of CSS was set. The patient began treatment with high doses of corticosteroids while montelukast was discontinued which resulted in disease remission. Conclusion. Although there is no evidence that leukotriene modifiers cause the CSS in all patients with asthma, in case of frequent exacerbations with the appearance of pulmonary infiltrates, eosinophilia and paranasal sinus abnormalities make one think of this form of vasculitis.

Unusual Respiratory Manifestations of Ankylosing Spondylitis – A Case Report

Abstract A male patient, 54 years old, was initially admitted to the hospital because of fatigue he felt during the last month and swelling of the lower legs. Upon hospital admittance, gas exchange analysis showed global respiratory failure: pO2=6.1 kPa, pCO2=10.9 kPa, pH=7.35, A-a gradient = 1.0. Due to the existence of hypercapnia and decompensated respiratory acidosis, the patient was connected to a device for non-invasive mechanical ventilation. Reduced chest mobility was noticed, and the respiratory index value was decreased. Radiographs of the chest and thoracic and lumbo-sacral spine showed marked changes on the spine attributable to ankylosing spondylitis (AS). Radiographs of the sacroiliac joints showed reduced sacroiliac joint intraarticular space with signs of subchondral sclerosis. The diagnosis of AS was set on the basis of New York Criteria (bilateral sacroiliitis, grade 3) and clinical criteria (back pain, lumbar spine limitation and chest expansion limitation). HLA typing (HLA B27 +) confirmed the diagnosis of AS. Pulmonary function test proved severe restrictive syndrome. Polysomnography verified the existence of severe obstructive sleep apnoea (AHI =73). This was a patient with newly diagnosed AS, with consequent severe restrictive syndrome and global respiratory failure with severe obstructive sleep apnoea. Thee patient was discharged from the hospital with a NIV (global respiratory failure) device for home use during the night.

Clinical Presentation Of The Abuse Of Insulin: Hypoglycaemic Coma And Aspiration Pneumonia In Non-Professional Bodybuilders

Abstract The use of medications that improve the physical performance of an individual represents a very serious worldwide health problem. The abuse of these medications is increasing. Herein, we describe a patient, at the age of 20, who was hospitalized due to loss of consciousness and difficulty breathing. At admission, the patient was unconsciousness, tahi-dyspnoic, and had a pale complexion and an athletic build. In gas analyses, extremely low saturation was observed, followed by acidosis, heavy hypoxia with normocapnia, higher lactates, hypocalcaemia and severe hypoglycaemia. The patient was treated with a hypertonic solution of glucose and intubated, with the aspiration of sanious content from the respiratory tract. After treatment, the patient woke from coma but was very confused. In the first 6 hours of hospitalization, severe hypoglycaemia occurred several times, despite the continuous administration of glucose. Due to the growth of inflammatory syndrome since the first day of hospitalization, the patient was kept in the hospital for treatment along with the administration of antibiotic treatment. On the fourth day of hospitalization, the patient stated that for the last year, he had been taking testosterone at a dose of 1 g a week, as well as tamoxifen pills and 15 i.j. of fast-acting human insulin (Actrapid®) daily for their combined anabolic effect. Hypoglycaemic coma, caused by the abuse of insulin, represents a severe complication in patients, which can be followed by confusion, a slowed thinking process, the weakening of cognitive functions and even death. It is necessary to invest great efforts into the prevention of the purchase of these medications via the Internet or on the black market for purposes of abuse in order to prevent such serious and life-threatening complications.

A rare case of coexistent intralobar and extralobar pulmonary sequestration

In the pathology of respiratory tract, sequestration presents as a non-functional lung tissue with no communication with tracheobronchial tree. It represents a rare congenital bronchopulmonary and vascular malformation, which occurs at a frequency of 0.1 to 6%. Intralobar and extralobar sequestrations are extremely rare congenital anomalies, especially if they occur at the same time in a patient. Proper diagnosis and appropriate surgical therapy, in the absence of associated anomalies, provide an excellent prognosis. In this paper, we are describing the simultaneous presence of intralobar sequestration (ILS) in the lower lobe of the left lung and extralobar sequestration (ELS) which is positioned on the aortic arch, in a 53 years old man. Two years post surgery, there is no recurrence or any patomorphological and functional disorders in the respiratory tract.