Tevfik Ozlu

Long-Term Outcomes in Acute Pulmonary Thromboembolism The Incidence of Chronic Thromboembolic Pulmonary Hypertension and Associated Risk Factors

The long-term outcomes of pulmonary thromboembolism (PTE) and/or incidence of chronic thromboembolic pulmonary hypertension (CTEPH) are not well documented. Three hundred twenty-five consecutive cases objectively diagnosed with PTE monitored for an average 16.3 months (6-50.7 months) were investigated. Data concerning recurrence, residual thrombus, mortality, and CTEPH in particular were collected. Chronic thromboembolic pulmonary hypertension frequency acute first episode of PTE was 4.6%. Chronic thromboembolic pulmonary hypertension developed within 12 months after PTE attack in approximately 80% of patients and it did not occur after 2 years. Residual chronic thrombus was determined at the 3rd month in 48% of cases post-PTE, at the 6th month in 27.4%, and at the 12th month in 18.2%. At multivariate regression analysis, systolic pulmonary arterial pressure > 50 mm Hg, hazard ratio: 10.1 (95% confidence interval: 4.1-71.2) were predictors of CTEPH. Chronic thromboembolic pulmonary hypertension develops as a serious complication in a significant number of cases with PTE. Closer monitoring of high-risk cases in particular is important in terms of early diagnosis and treatment.

The role of risk factors in delayed diagnosis of pulmonary embolism.

BACKGROUND Despite diagnostic advances, delays in the diagnosis of pulmonary embolism (PE) are common. OBJECTIVE In this study, we aimed to investigate the relationship between delays in the diagnosis of PE and underlying risk factors for PE. METHODS We retrospectively evaluated the records of 408 patients with acute PE. Patients were divided into 2 groups, surgical or medical, based on risk factors leading to the embolism. Analysis involved demographic characteristics of the patients, dates of symptom onset, first medical evaluation, and confirmatory diagnostic tests. Diagnostic delay was described as diagnosis of PE more than 1 week after symptom onset. RESULTS The mean time to diagnosis for all patients was 6.95 ± 8.5 days (median, 3 days; range, 0-45 days). Of the total number of patients, 29.6% had presented within the first 24 hours and 72.3% within the first week. The mean time to diagnosis was 4.4 ± 7.6 days (median, 2 days; range, 0-45 days) in the surgical group and 8.0 ± 8.6 days (median, 4 days; range, 0-45 days) in the medical group (P = .000). The mean time to diagnosis in the medical group was approximately 4 times greater than that of the surgical group on univariate analysis. Early or delayed diagnosis had no significant impact on mortality in either group. CONCLUSION Delay in the diagnosis of PE is an important issue, particularly in medical patients. We suggest that a public health and educational initiative is needed to improve efficiency in PE diagnosis.

Prognostic Value of Red Cell Distribution Width in Patients With Pulmonary Embolism

Elevated red blood cell distribution width (RDW) has been associated with adverse outcomes of heart failure and pulmonary hypertension. A total of 702 consecutive patients with acute pulmonary embolism (PE) were evaluated. There was a graded increase in mortality rate with RDW quartiles of 5.8% in quartile I (≤13.6), 9.7% in quartile II (13.7%-14.5%), 13.1% in quartile III (14.6%-16.3%), and 20% in quartile IV (>16.3%; P < .001). Patients who died had higher baseline RDW values (16.1% [11.7-28.3] vs 14.5% [10.7-32.5]; P < .001). The optimal cutoff value of RDW for predicting in-hospital mortality was ≥15%. The area under the curve of mortality for RDW was 0.649 (confidence interval [CI]: 0.584-0.715); the negative predictive value was 93%. In multivariable regression analysis, RDW remained associated with an increased odds of death (odds ratio: 1.2, 95% CI: 1.1-1.4). High RDW level was an independent predictor of short-term mortality in PE. The RDW levels may provide a potential marker to predict outcome in patients with PE.

Combined risk stratification with computerized tomography /echocardiography and biomarkers in patients with normotensive pulmonary embolism☆ , ☆☆

BACKGROUND Right ventricular dysfunction (RVD) detected by computerized tomography (CT)/echocardiography or elevated biomarkers is associated with a poor prognosis for pulmonary embolism (PE). However, these prognostic factors have not previously been concomitantly elucidated in the same patient group. METHODS This prospective study included 108 consecutive patients with normotensive PE confirmed by CT pulmonary angiography (CTPA). On admission, patient serum NT-proBNP and troponin T (Tn-T) levels were measured, and echocardiography was performed within 24 hours after diagnosis of PE. Receiver operating characteristic (ROC) analysis was performed to determine the optimal echocardiographic end-diastolic diameters of the right ventricle, the ratio of the right ventricle to left ventricle (RV/LV ratio) on CTPA, and NT-proBNP and Tn-T cut-off levels with regard to prognosis. RESULTS All-cause 30-day mortality was 13% and PE-related mortality was 5.6%. RVD was defined as a right/left ventricular dimension ratio≥1.1 on CTPA and RV>30 mm on echocardiography by ROC analysis. A cut-off level of NT-proBNP≤90 pmol/ml had a high positive predictive value of 98% for survival, whereas NT-proBNP>300 and Tn-T≥0.027 had a negative predictive value, for all-cause deaths, of 95% and 96%, respectively. PE mortality in patients with NT-proBNP>300 and Tn-T≥0.027 reached 64%. In univariable analysis, the combination of Tn-T≥0.027 ng/ml with a echocardiographic RVD were the most significant predictors of overall mortality and PE-related death [HR: 14 (95% CI: 4.6-42,) and HR: 37.6 (95% CI: 4.4-324)], respectively. In multivariable Coxs regression analysis, NT-proBNP>300 and Tn-T≥0.027 HR: 26.5 (95% CI: 4.1-169.9, p<0.001) were the best combination to predict all-cause of mortality. CONCLUSIONS The combination of NT-proBNP and Tn-T clearly appears to be a better risk stratification predictor than biomarkers plus RVD on CT/ echocardiography in patients with normotensive PE.

Time Delay between Onset of Symptoms and Diagnosis in Pulmonary Thromboembolism

Background: Although pulmonary thromboembolism is usually considered as an acute illness, delayed presentations are fairly common. Objective: The purpose of this study was to investigate delays to presentation/diagnosis and their likely correlation with patients’ clinical and radiographic findings in pulmonary thromboembolism. Methods: All cases of pulmonary embolism diagnosed in our hospital between March 2002 and May 2006 were reviewed for the date of symptom onset, the dates of presentation and diagnosis, clinical findings, localization of embolism in pulmonary vascular tree and pleuropulmonary changes arising secondary to thrombotic occlusion. The parameters related to presentation delays were analyzed using a Mann-Whitney U test and logistic regression analysis. Results: Of the 178 patients enrolled, 30.4% presented to hospital 1 week after the start of their symptoms and there was an average of 8.4 ± 11.4 days’ (median 4 days, range 0–75) delay to presentation. The delay from presentation to diagnosis was 0.9 ± 1.9 days (median 0, range 0–16). Patients with hypotension, respiratory rate >20 and atelectasis in spiral CT presented earlier. However, no correlation was found between delays and the level of thromboembolic occlusion in pulmonary artery. Conclusion: Pulmonary thromboembolism should be considered not only in an acute setting, but also in patients with prolonged respiratory symptoms, since there was a significant delay to presentation amongst our patients. The presence of hypotension and a high respiratory frequency was clearly associated with early presentation.

Time course from first symptom to the treatment of lung cancer in the Eastern Black Sea Region of Turkey.

Objectives: To determine the delay between the onset and the diagnosis and treatment of patients with lung cancer in two cancer centres in the Eastern Black Sea Region of Turkey. Subjects and Methods: The records of 226 patients (217 males, 9 females) were evaluated retrospectively for the dates noted for the onset of symptoms, first presentation to a physician, histopathological diagnosis and start of treatment. The median time intervals from the appearance of the first symptom to definitive diagnosis and treatment were calculated. Results: The patients presented to their physicians 30 (range 2–365) days after their complaints began. The time that elapsed between admission and histopathological diagnosis and between the diagnosis and initiation of therapy were 8 (range 1–210) and 17.5 days (range 0–206), respectively. The median time span from presentation to treatment was 30 days (range 1–253). There were no significant time interval differences between onset of symptoms and first presentation and the subsequent diagnostic and therapeutic processes for histopathology, stage of the tumour and treatment procedures (p > 0.05). Conclusion: Reasons for the delayed treatment of lung cancer patients were late presentation to the physician and the long time interval between tissue diagnosis and treatment. This delay was mostly associated with a large number of patients and delayed appointments for imaging procedures – the result of organisational problems within the health services of Turkey.

Meteorological parameters and seasonal variations in pulmonary thromboembolism

BACKGROUND AND OBJECTIVES In recent years, circannual variations in incidence and mortality for venous thromboembolic disease have been demonstrated, with a peak in winter. However, several investigators have observed no seasonal variation in these diseases. The aim of our study was to investigate whether a seasonal variation, in terms of atmospheric pressure, humidity, and temperature, exists for pulmonary thromboembolism. METHOD We retrospectively included 206 patients with a diagnosis of pulmonary embolism (PE) between 1 June 2001 and 31 May 2006. RESULTS The highest number of cases in the 5 years concerned occurred in May (29 cases). Although PE occurred most commonly in the spring (72 cases) and autumn (51 cases), the difference was statistically significant (P = .003). There were no case correlations with months and pressure, temperature, or humidity. However, there was a statistically significant positive correlation between case incidence and atmospheric pressure (r = 0.53, P < .0005) and humidity (r = 0.57, P < .0005). In terms of risk factors, seasonal distribution was not statistically significant as regards cases of embolism occurring for surgical or nonsurgical reasons (r = 0.588). CONCLUSION In terms of the relationship between seasons and embolism cases, despite the determination of an insignificant positive correlation, a statistically significant positive correlation was determined between air pressure and humidity and case incidence. There is now a need for further wide-ranging prospective studies including various hematological parameters to clarify the correlation between PE and air pressure.

Red cell distribution width: A new predictor for chronic thromboembolic pulmonary hypertension after pulmonary embolism

The most important long-term complication of pulmonary thromboembolism is chronic thromboembolic pulmonary hypertension (CTEPH) that is associated with considerable morbidity and mortality. It is uncertain why some patients with acute pulmonary embolism (PE) develop CTEPH and others do not. Elevated red cell distribution width (RDW) has been associated with adverse outcomes of heart failure, PE, and idiopathic pulmonary hypertension. The aim of the present study was to investigate whether RDW might be a predictor of CTEPH in PE patients or not. This study is a retrospective cohort study. A total of 203 consecutive patients with acute PE were included. The RDW was higher in the CTEPH patients than the patients without CTEPH (17.04 ± 3.46, 14.64 ± 1.82, respectively, p = 0.015). RDW was also higher in the CTEPH patients at the time of diagnosis of CTEPH during follow-up compared with the baseline RDW level at the time of PE diagnosis (18.63 ± 3.58, 17.02 ± 3.59, respectively, p = 0.014). The optimal cutoff value of the RDW for predicting CTEPH was 14.65. The area under the curve of RDW for the prediction of CTEPH was 0.735 (95% confidence interval (CI): 0.600–0.869); in cases with RDW levels >14.65%, the specificity, sensitivity, and negative predictive value for CTEPH were 62% (95% CI: 0.55–0.69), 75% (95% CI: 0.47–0.92), and 96.7% (95% CI: 0.91–0.99), respectively. A multivariate regression analysis showed that RDW, hazard ratio: 1.58 (95% CI: 1.09–2.30), was a predictor of CTEPH (p = 0.016). High level of RDW was an independent predictor of CTEPH in PE patients. Therefore, RDW levels may provide a prediction for CTEPH in PE patients.

Wegener’s Granulomatosis with Parotid Gland Involvement and Pneumothorax

Objective: Wegener’s granulomatosis is a systemic vasculitis characterized by necrotizing granulomatous lesions mostly involving the upper and lower respiratory tract. The disease rarely causes parotid gland involvement and pneumothorax. We report a case of Wegener’s granulomatosis involving parotid gland, and complicated with a pneumothorax. Clinical Presentation: A 45-year-old man admitted with a 3-week history of painful left parotid gland enlargement and hemoptysis. On physical examination a painful and hard mass was detected on the left pre-auricular area. Cervical CT revealed a 2 × 1.5 cm hypodense lesion mimicking an abscess on the left parotid gland. Chest radiograph and thorax CT demonstrated nodular and cavitating opacities on the right and left upper zones. There were numerous erythrocytes in urine sediment. The drained pus material from the parotid abscess demonstrated only gram-positive cocci (Staphylococcus aureus). Two weeks treatment with teicoplanin resulted in no improvement. Meanwhile, parotid gland biopsy revealed necrotizing granulomatous inflammation. There was a sixfold increase in serum cANCA levels. With the diagnosis of Wegener’s granulomatosis, cyclophosphamide and prednisolone were initiated. However, 1 month later, pneumothorax developed as a complication of rupture of a cavitary lesion. Conclusion: Parotid gland swelling may be the initial presenting symptom of Wegener’s granulomatosis. It can be confused with infectious or malignant diseases of the gland, and the lung involvement may be complicated with pneumothorax.

An Unusual Endobronchial Foreign Body: A Gauze That Migrated from the Mediastinum

The authors report a 48-year-old white male with lung cancer who was admitted to their clinic with a 1-year history of cough and shortness of breath. The patient was hospitalized because of progression of his complaints over 1 month. On the 3rd day of hospitalization, he expectorated a piece of gauze. The authors performed a fiber-optic bronchoscopy and saw pieces of gauze originating from granulation tissue located in the angle of the lower trachea and left main bronchi. A detailed anamnesis revealed that a mediastinoscopy had been performed 3 years ago for lung cancer staging: the gauze had migrated from the mediastinum to the endobrochial space.