Shin-Yup Lee

Prognostic implications of computed tomographic right ventricular dilation in patients with acute pulmonary embolism

INTRODUCTIONnWhether right ventricular (RV) dilation on computerized tomography (RVD-CT) is a useful predictor for clinical outcomes of acute pulmonary embolism (PE) remains debatable. Furthermore, data regarding the best combination of prognostic markers for predicting the adverse outcome of PE are limited.nnnMATERIALS AND METHODSnThe authors retrospectively reviewed 657 consecutive patients hospitalized at a tertiary referral center with a diagnosis of PE based on multi-detector row CT scan.nnnRESULTSnPatients were allocated into an adverse outcome group (11% [n = 69]) or a low risk group (89% [n = 588]). Multivariate analysis showed that RVD-CT (RV/left ventricle [LV] diameter ratio ≥ 1), high pulmonary embolism severity index (PESI) score (class IV-V), high N-terminal-pro-B-type natriuretic peptide (NT-proBNP,≥ 1,136 pg/ml), and elevated troponin I (≥ 0.05 ng/ml) significantly predicted an adverse outcome (odds ratio [OR] 6.26, 95% confidence interval [CI] 2.74-14.31, p < 0.001; OR 4.71, 95% CI 2.00-11.07, p < 0.001; OR 2.71, 95% CI 1.15-6.39, p = 0.023; and OR 3.00, 95% CI 1.27-7.07, p = 0.012, respectively). The addition of RVD-CT to PESI, NT-proBNP, troponin I or their combinations enhanced the positive predictive values and positive likelihood ratios of an adverse outcome.nnnCONCLUSIONSnRVD-CT could be an independent prognostic factor of adverse outcomes in patients with acute PE, and provides additional prognostic value when combined with other prognostic factors.

Clinical relevance and characteristics of pleural effusion in patients with Mycoplasma pneumoniae pneumonia

Abstract Data regarding parapneumonic pleural effusion in Mycoplasma pneumoniae pneumonia (MP) patients are limited. In this study MP patients with pleural effusion tended to be younger and had longer hospital stays and more common use of systemic steroids compared to those without pleural effusion. In 5 of the 6 patients for whom pleural fluid data were available, the pleural effusion was lymphocyte-predominant rather than polymorphonuclear leukocyte-predominant; these patients also had elevated adenosine deaminase levels. Taken together, these results indicate that MP patients with pleural effusion may have a more severe form compared to those without pleural effusion. M. pneumoniae should be considered an aetiological agent of lymphocyte-predominant pleural effusion.

Central emboli rather than saddle emboli predict adverse outcomes in patients with acute pulmonary embolism

INTRODUCTIONnIn patients with acute pulmonary embolism (PE), the prognostic implications of saddle or central emboli, as observed on computed tomography (CT), remain to be established. The aim of the present study was to assess whether the presence of saddle and central emboli could be used to predict clinical outcomes in patients with PE.nnnMATERIALS AND METHODSnThe authors retrospectively reviewed 743 consecutive patients hospitalized at a tertiary referral center with a diagnosis of PE based on multi-detector row CT scan.nnnRESULTSnAll the clinical variables did not differ between saddle emboli (5.8% [n = 43]) and right or left pulmonary artery emboli (29.7% [n = 221]), and the frequency of an adverse outcome was not significantly different between the two groups. Saddle emboli and right or left pulmonary artery emboli were grouped into central emboli (35.5% [n = 264]). Patients were allocated to an adverse outcome group (10.5% [n = 78]) or a control group (89.5% [n = 665]). Multivariate analysis demonstrated that PE severity index (PESI) score (class IV-V), N-terminal-pro-B-type natriuretic peptide level (≥ 1,406 pg/mL), right ventricular dilation on CT (right ventricle/left ventricle diameter ratio ≥ 1), and central emboli significantly predicted an adverse outcome. The addition of central emboli to other established prognostic factors such as PESI enhanced the positive predictive values and positive likelihood ratios of an adverse outcome for acute PE.nnnCONCLUSIONSnRather than saddle emboli, central emboli could be an independent prognostic factor of adverse outcomes in patients with acute PE and provide additional prognostic value when combined with other prognostic factors.

Focal necrotizing pneumonia is a distinct entity from lung abscess

‘Focal necrotizing pneumonia’ was defined as a localized type of necrotizing pneumonia characterized by a single or few cavities of low density without rim enhancement on computed tomography (CT) scan. The purpose of this study was to investigate the clinical features and course of patients with focal necrotizing pneumonia, thereby elucidating its clinical relevance.

Clinical relevance of pulmonary infarction in patients with pulmonary embolism

INTRODUCTIONnData regarding the clinical relevance of pulmonary infarction (PI) in patients with pulmonary embolism (PE) are lacking. The aim of this study was to investigate the clinical features of PE patients with PI and the prognostic role of PI for PE patients.nnnMATERIALS AND METHODSnBased on computed tomography scan, 509 patients with PE were divided into two groups, the infarction group (n=45) and the non-infarction group (n=464). A variety of clinical parameters were compared between the two groups.nnnRESULTSnIn the infarction group, the largest pulmonary arteries involved by emboli were central rather than peripheral and more proximal as compared to the non-infarction group (p=0.01 and p<0.03, respectively). Thrombolytic agents tended to be more frequently administered in the infarction group (13.3% [n=6] versus 6.3% [n=29], p=0.07). In-hospital mortality, PE-related deaths, and the recurrence rate of PE did not differ between the two groups.nnnCONCLUSIONSnThe present study did not demonstrate that PI is a prognostic indicator of recurrence and mortality in PE patients. We suggest the possibility that blood clot burden is greater in PE patients with PI, although PI by itself occurs in small pulmonary arteries.

A Positive Feedback Loop between Sestrin2 and mTORC2 Is Required for the Survival of Glutamine-Depleted Lung Cancer Cells

Proper regulation of mTORC1 and mTORC2 upon nutrient starvation is critical for cancer cell survival.xa0Upregulation of Sestrin2 in response to glutamine deprivation rescues cell death by suppressing mTORC1. However, the contribution of mTORC2 to Sestrin2-mediated mTORC1 suppression remains unclear. Here, we report that both Sestrin2 and mTORC2 are upregulated in glutamine-depleted lung cancer cells. Moreover, glutamine depletion caused Sestrin2 to associate with mTORC2, which was required for the increase in Sestrin2 protein stability and the reduction in mTORC1 activity. Ultimately, differential regulation of mTORC1 and 2 by Sestrin2 reprogramed lipid metabolism and enabled glutamine-depleted lung cancer cells to survive by maintaining energy and redox balance. Importantly, combined inhibition of glutamine utilization and Sestrin2 induced lung cancer cell death both inxa0vitro and inxa0vivo. This study shows that differential Sestrin2-mediated regulation of mTORC1 and mTORC2 is necessary for the survival of glutamine-depleted lung cancer cells.

Multimarker Prognostication for Hospitalized Patients with Community-acquired Pneumonia.

OBJECTIVEnThe optimal prognostic model for community-acquired pneumonia (CAP) remains unclear. In this study, we sought to identify independent predictors of 30-day mortality in patients with CAP and to determine whether adding specific prognostic factors to each of the two clinical prediction scores could improve the prognostic yield.nnnMETHODSnThis retrospective study involved 797 CAP patients who had been hospitalized at a tertiary referral center. The patients were categorized into two groups: those who survived and those who had died on or before 30 days after admission. Select clinical parameters were then compared between the two groups.nnnRESULTSnDuring the 30-day period, there were 72 deaths (9%). We constructed two models for a multivariate analysis: one was based on a high CURB-65 score (3-5) and the other on a high pneumonia severity index (PSI) class (V). In both models, a high CURB-65 score or a high PSI class, along with the presence of dyspnea, high Eastern Cooperative Oncology Group (ECOG) performance status (3-4), and a low serum albumin level, were independent predictors of 30-day mortality. In both the CURB-65-based and PSI-based models, the addition of dyspnea, high ECOG performance status, and hypoalbuminemia (<3 g/dL) enhanced the prognostic assessment, and subsequently, the c-statistics calculated with the use of three- or four- predictor combinations exceeded 0.8.nnnCONCLUSIONnIn addition to the CURB-65 or PSI, the clinical factors of dyspnea, the ECOG performance status, and serum albumin level may be independent predictors of 30-day mortality in CAP patients. When combined with the CURB-65 or PSI, these parameters provide additional evidence for predicting poor prognoses.

Predictors of Relapse in Patients with Organizing Pneumonia.

Background Although organizing pneumonia (OP) responds well to corticosteroid therapy, relapse is common during dose reduction or follow-up. Predictors of relapse in OP patients remain to be established. The aim of the present study was to identify factors related to relapse in OP patients. Methods This study was retrospectively performed in a tertiary referral center. Of 66 OP patients who were improved with or without treatment, 20 (30%) experienced relapse. The clinical and radiologic parameters in the relapse patient group (n=20) were compared to that in the non-relapse group (n=46). Results Multivariate analysis demonstrated that percent predicted forced vital capacity (FVC), PaO2/FiO2, and serum protein level were significant predictors of relapse in OP patients (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.70-0.97; p=0.018; OR, 1.02; 95% CI, 1.00-1.04; p=0.042; and OR, 0.06; 95% CI, 0.01-0.87; p=0.039, respectively). Conclusion This study shows that FVC, PaO2/FiO2 and serum protein level at presentation can significantly predict relapse in OP patients.

Clinical Characteristics of Community-Acquired Viridans Streptococcal Pneumonia

Background Viridans streptococci (VS) are a large group of streptococcal bacteria that are causative agents of community-acquired respiratory tract infection. However, data regarding their clinical characteristics are limited. The purpose of the present study was to investigate the clinical and radiologic features of community-acquired pneumonia (CAP) with or without parapneumonic effusion caused by VS. Methods Of 455 consecutive CAP patients with or without parapneumonic effusion, VS were isolated from the blood or pleural fluid in 27 (VS group, 5.9%) patients. Streptococcus pneumoniae was identified as a single etiologic agent in 70 (control group) patients. We compared various clinical parameters between the VS group and the control group. Results In univariate analysis, the VS group was characterized by more frequent complicated parapneumonic effusion or empyema and bed-ridden status, lower incidences of productive cough, elevated procalcitonin (>0.5 ng/mL), lower age-adjusted Charlson comorbidity index score, and more frequent ground glass opacity (GGO) or consolidation on computed tomography (CT) scans. Multivariate analysis demonstrated that complicated parapneumonic effusion or empyema, productive cough, bed-ridden status, and GGO or consolidation on CT scans were independent predictors of community-acquired respiratory tract infection caused by VS. Conclusion CAP caused by VS commonly presents as complicated parapneumonic effusion or empyema. It is characterized by less frequent productive cough, more frequent bed-ridden status, and less common CT pulmonary parenchymal lesions. However, its treatment outcome and clinical course are similar to those of pneumococcal pneumonia.

Prognostic Value of Serum Growth Differentiation Factor-15 in Patients with Chronic Obstructive Pulmonary Disease Exacerbation

Background Information regarding prognostic value of growth differentiation factor 15 (GDF-15) and heart-type fatty acid-binding protein (H-FABP) in patients with chronic obstructive pulmonary disease (COPD) exacerbation is limited. The aim of this study was to investigate whether serum levels of GDF-15 and H-FABP predict an adverse outcome for COPD exacerbation. Methods Clinical variables, including serum GDF-15 and H-FABP levels were compared in prospectively enrolled patients with COPD exacerbation that did or did not experience an adverse outcome. An adverse outcome included 30-day mortality and need for endotracheal intubation or inotropic support. Results Ninety-seven patients were included and allocated into an adverse outcome (n=10) or a control (n=87) group. Frequencies of mental change and PaCO2>37 mm Hg were significantly higher in the adverse outcome group (mental change: 30% vs. 6%, p=0.034 and PaCO2>37 mm Hg: 80% vs. 22%, p<0.001, respectively). Serum GDF-15 elevation (>1,600 pg/mL) was more common in the adverse outcome group (80% vs. 43%, p=0.041). However, serum H-FABP level and frequency of serum H-FABP elevation (>755 pg/mL) did not differ between the two groups. Multivariate analysis showed that an elevated serum GDF-15 and PaCO2>37 mm Hg were significant predictors of an adverse outcome (odds ratio [OR], 25.8; 95% confidence interval [CI], 2.7-243.8; p=0.005 and OR, 11.8; 95% CI, 1.2-115.3; p=0.034, respectively). Conclusion Elevated serum GDF-15 level and PaCO2>37 mm Hg were found to predict an adverse outcome independently in patients with COPD exacerbation, suggesting the possibility that serum GDF-15 could be used as a prognostic biomarker of COPD exacerbation.