Miloslav Marel

Management of Benign Stenoses of the Large Airways in the University Hospital in Prague, Czech Republic, in 1998–2003

Background: Clinically significant benign stenoses of the large airways develop in about 1% of patients after intubation. The management of benign stenoses is not unified around the world, nor are there any accepted methods for their screening. Objectives: The purpose of this study is to describe and compare results of interventional bronchoscopy and surgical therapy of benign stenoses as well as to propose an algorithm for the management of this airways disorder. Methods: Prospective study on 80 consecutive patients with benign stenoses of the large airways admitted to the Pulmonary Department of the University Hospital of Prague-Motol. Results: Sixty-two patients developed stenoses after endotracheal intubation or tracheostomy, in 18 patients the stenosis was caused by other diseases or pathological situations. Thirty-eight patients were sent for surgical resection of the stenotic part of the airways. 2 surgically treated patients developed recurrence of the stenosis and had to be reoperated on. Narrowing of the trachea at the site of end-to-end anastomosis developed in 6 other patients and was cured by interventional bronchoscopy. The remaining 42 patients were treated by interventional bronchoscopy (Nd-YAG laser, electrocautery, stent) which was curative in 35 patients. Sixty-five patients were alive at the time of evaluation, 15 patients died. Five of them died between 3 and 14 (median 4) months after surgery from a disease other than airway stenosis. Ten nonresected patients also died, with 1 exception, due to a disease other than airway stenosis; the median survival was 9 months. Conclusions: We recommend to assess the patient for surgery after the initial diagnosis and therapeutic bronchoscopy with dilatation of the stenosis. If the patient is not a suitable candidate for resection, interventional bronchoscopy is an appropriate alternative for the management of benign stenoses of the large airways.

Epidemiological studies on lung cancer in the Bohemia region.

In this epidemiological study, the incidence of lung cancer from 1981 to 1985 was evaluated in one district in the Central Bohemia Region with a population of 44,000. A total of 157 patients were identified as having lung cancer, the male:female ratio was 10:1, and 91% were smokers. Up to 78% of patients were detected because of their complaints, 17% at preventive examination, and 5% at autopsy. The calculated incidence for men was 129/100,000, for women 13/100,000. An average of 42 days elapsed from the time of the initial complaints or the preventive examination to the first visit with a pneumologist. From this visit to the establishment of the diagnosis an average of 28 days elapsed. In 79% of the patients, the diagnosis was confirmed histo- or/and cytologically, but mostly only by cytological examination; 15% of the whole group (23 patients) received surgery, four of whom underwent explorative thoracotomy alone; 18% had radiotherapy only; 12% received radiotherapy in combination with chemotherapy; 9% had chemotherapy alone; and 46% received symptomatic therapy only. In April 1992, the authors reviewed the series of patients and evaluated survival in different subgroups according to method of detection, morphological type, and TNM stage. Of the patients undergoing resection, 37% survived 5 years. In 13 patients, who died after successful resection, the cause of death was analysed. The majority succumbed to progression and dissemination of lung cancer. The authors conclude that prolonged survival could be demonstrated for resected patients, for patients at stages I and II, and for patients with squamous type of cancer.

The results of surgical treatment of non-small cell lung cancer at the Pneumological Clinic in Prague, Czech Republic 1985-1990.

In the Czech Republic, lung cancer is the most frequent malignant tumor in men. In 1990 the incidence was 99.6/100,000 for men and 15.8/100,000 for women. Neither diagnostic nor therapeutic approaches have changed significantly in the last 10 years. Patients undergoing lung resection have a chance of long-term survival. In this retrospective study, the authors analysed the data of 252 patients undergoing the operation for non-small cell lung cancer (NASCL) in the period 1985-1990. Of all patients who in that period had lung cancer diagnosed in our clinic, only 22% were operated on. Lobectomy was the most frequent type of operation (45%), and exploratory thoracotomy was carried out in 13%. The epidermoid type of cancer was the most frequent one (62%). Comparing cTNM with pTNM, concordant results were found in 55% of the series, 39% were clinically underestimated and 6% overestimated. By the time of the evaluation (31 December 1992), 78% of all patients who had undergone surgery during the study period had died. The most frequent cause of death was lung cancer metastasis. In the subseries of patients who died within 1 month after surgery (10% of all patients), the most frequent cause of death was pneumonia. The survival curve shows the best prognosis for patients in the Ist TNM stage, with 40% surviving 5 years. The authors consider the results of this study to favour aggressive surgical treatment of NSCLC patients.

Ivacaftor in cystic fibrosis adults: Czech experience with six years of follow-up

AIMS Ivacaftor is a revolutionary treatment option for cystic fibrosis (CF) patients with G551D and other gating mutations. The aim of this study was to evaluate the clinical status of patients on ivacaftor who were followed for up to 6 years together with an evaluation of ivacaftor therapy in one patient with an initial FEV1 less than 40% of predicted value. METHODS Data on development of clinical status and sinopulmonary-related therapies were obtained from patient health records during ivacaftor treatment lasting for up to six years and were compared with an equivalent period before ivacaftor administration. RESULTS Five CF adults with a median age 28.6 years (range 21.4-35.6 years) with median FEV1 45% pred. (range 16-85% pred.) were included in the study. Four subjects were also participants in the STRIVE and PERSIST studies. Altogether, twenty-four patient-years of ivacaftor treatment were analyzed. The median FEV1 decline per year decreased from -4.5 to -0.9% pred. (P = 0.043). Reduction in number of days on antibiotic treatment and hospital stays was 21% (P < 0.001) and 75% (P = 0.003), respectively. Improvement and stabilization of lung function was observed for up to six years of treatment. In a patient with severe airway obstruction, an increase in the FEV1 value (30.4% from baseline) was documented during the first twelve months of treatment. CONCLUSION Ivacaftor therapy resulted in improved and stabilized lung function in up to six years of treatment with a reduction in number of days on antibiotic treatment and hospital stays. Its efficiency was also displayed in a patient with severe airway obstruction.

Vanishing Lung Syndrome in a Cystic Fibrosis Patient

Fig. 1. Chest X-ray and chest CT. (a) Posteroanterior chest X-ray shows hyperlucent upper parts of both lung fields, approx. upper half on the right side and upper third on the left side. Residual lung parenchyma has increased bronchovascular markings; (b) Chest CT (sagittal reconstruction) at the level of left hilum shows vanishing lung in the upper third of left lung; (c) Chest CT (coronal reconstruction) at the level of main bronchi shows bronchiectasis in the left upper lobe ending in severe emphysematous changes of lung parenchyma, vanishing lung in both upper zones, large bulla in the right lower lobe and consolidation in basolateral part of the right upper lobe.

Acute exacerbations of COPD: The influence of comorbidities and chronic medication on mortality and exacerbation rate

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the developed world and represents an important public health challange. The COPD burden is considered to increase in the future because of ageing population and continued exposure to COPD risk factors. We have consecutively collected data from patients with mild or severe exacerbation, requiring admission either to intensive care unit (ICU) or to our main ward. During the year 2014, there were 226 COPD exacerbations requiring admission to hospital, 31 exacerbations were treated in ICU and 195 in our main ward. A prospective study in a well caracterised cohort of our patients was performed. We have assessed whether presence of comorbidities (diabetes, ischemic heart disease, arterial hypertension, atrial fibrillation, asthma, cancer, peptic ulcer disease, osteoporosis and depression), severity of airway obstruction or specific COPD fenotype were related to exacerbation frequency and resulting mortality of our patients. We have found that patients with frequent exacerbations (≥ 2 per year) had significantly more often asthma (22.7%) and atopic syndrome (25%) compared to patients with single exacerbation per year (7.3% and 10.1%, p=0.00174 and p=0.0075) On the other hand, there was no significantly increased prevalence of depression or ischemic heart disease in patients with frequent exacercerbations. Futhermore we haven´t found that using inhaled corticoseroids had an influence on the exacerbation rate of our patients. Existence of atopy, asthma bronchiale and astma/COPD overlap syndrome increase the frequency of exacerbations in COPD patients.

New and Existing Risk Factors in Patients With Hypertrophic Cardiomyopathy

Editorial New and Existing Risk Factors in Patients With Hypertrophic Cardiomyopathy Josef Veselka, MD, PhD, Miloslav Marel, MD, PhD, and Morten Kvistholm Jensen, MD, PhD Department of Cardiology, Motol University Hospital and 2nd Medical School, Charles University, Prague, Czech Republic Department of Pneumology, Motol University Hospital and 2nd Medical School, Charles University, Prague, Czech Republic Department of Cardiology, Copenhagen University Hospital, The Heart Center, Rigshospitalet, Copenhagen, Denmark

Lung cancer, pulmonary emphysema and pleural effusion: An autopsy study

OBJECTIVES To determine the exact incidence of lung cancer, pulmonary emphysema and pleural effusion we decided to carry out an autopsy study. METHODS In this autopsy study carried out over two years, we compared the results of autopsy findings with the clinical data in accompanying records of the deceased. RESULTS Among the 708 deceased subjects, there were 398 males and 310 females with a median age of 71 years. At autopsy, 55 cases of lung carcinoma (BCA) were found, of which 24 have not been identified during life (44%). Among the deceased with BCA, emphysema was also observed at autopsy in 40% of the cases. Pulmonary emphysema was described macroscopically in 28% of the full set of 708 deceased, whereas the accompanying records of the deceased described this condition in only 12% of the cases. Microscopic changes compatible with emphysema were identified in 54% of the examined lungs. Pleural effusions were described in the accompanying records of 13% of the deceased, while the autopsies showed this condition in 33% of the deceased. BCA was accompanied by effusion in 25% of the cases. CONCLUSIONS The obtained results show that the studied conditions are present in more cases than are reported by clinicians. The study confirms the commonly accepted association between lung cancer and emphysema.