Search results for: acute pulmonary thromboembolism

Authors: Ryan M. Monti, Bijal Mehta

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In cases of massive pulmonary embolism, defined as acute pulmonary embolism presenting with systemic hypotension or right ventricular dysfunction and impending failure, there is indication that unconventional therapies, such as phosphodiesterase inhibitors, endothelin receptor antagonists, and/or prostacyclin analogs may decrease the morbidity and mortality. Based on the premise that dilating the pulmonary artery will decrease the pulmonary vascular pressure, while simultaneously decreasing the aggregation of platelets, it can be hypothesized that increased blood flow through the pulmonary artery will decrease right heart strain and subsequent morbidity and mortality. While this theory has yet to be formally studied, the recommendations for treating massive pulmonary embolism with phosphodiesterase inhibitors, endothelin receptor antagonists, and/or prostacyclin analogs in conjunction with the current standards of care in massive pulmonary embolism should be formally studied. In particular, patients with massive PE who are unable to undergo thrombolysis/surgical intervention may be the ideal population to study the use of these treatments to determine any decrease in mortality and morbidity (short term and long term).

Keywords: acute pulmonary thromboembolism, treatment of pulmonary embolism, use of phosphodiesterase inhibitors, endothelin receptor antagonists, prostacyclin analogs in PE

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Authors: May Zaw, Amber Latif, William Lim

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Postpartum dyspnea can be due to many causes, such as pulmonary embolism, amniotic fluid embolism, and peripartum cardiomyopathy, but less frequently due to acute pulmonary edema. The incidence of acute pulmonary edema during pregnancy and in the postpartum period has been estimated to be around 0.08%. About half of the cases are attributed to tocolytic therapy. Herein, we present a case of a young woman presenting with acute hypoxia after induction of labor with oxytocin and found to have acute pulmonary edema. This case aims to illustrate and add to a growing body of literature regarding oxytocin-induced acute pulmonary edema and highlights the importance of recognizing the rare complication of oxytocin and necessary interventions to avoid complications. Oxytocin-induced pulmonary edema is a relatively uncommon condition, but physicians should have a high index of suspicion to initiate timely intervention and avoid fetal complications.

Keywords: pulmonary, pregnancy, oxytocin, postpartum

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Authors: Dipti Chand, Riya Saboo

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OBJECTIVES: Early and correct diagnosis may present a significant clinical challenge in diagnosis of patients presenting to Emergency Department with Acute Dyspnoea. The common cause of acute dyspnoea and respiratory distress in Emergency Department are Decompensated Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD), Asthma, Pneumonia, Acute Respiratory Distress Syndrome (ARDS), Pulmonary Embolism (PE), and other causes like anaemia. The aim of the study was to measure NT-pro Brain Natriuretic Peptide (BNP) and exhaled End-Tidal Carbon dioxide (ETCO2) in patients presenting with dyspnoea. MATERIAL AND METHODS: This prospective, cross-sectional and observational study was performed at the Government Medical College and Hospital, Nagpur, between October 2019 and October 2021 in patients admitted to the Medicine Intensive Care Unit. Three groups of patients were compared: (1) HFrelated acute dyspnoea group (n = 52), (2) pulmonary (COPD/PE)-related acute dyspnoea group (n = 31) and (3) sepsis with ARDS-related dyspnoea group (n = 13). All patients underwent initial clinical examination with a recording of initial vital parameters along with on-admission ETCO2 measurement, NT-proBNP testing, arterial blood gas analysis, lung ultrasound examination, 2D echocardiography, chest X-rays, and other relevant diagnostic laboratory testing. RESULTS: 96 patients were included in the study. Median NT-proBNP was found to be high for the Heart Failure group (11,480 pg/ml), followed by the sepsis group (780 pg/ml), and pulmonary group had an Nt ProBNP of 231 pg/ml. The mean ETCO2 value was maximum in the pulmonary group (48.610 mmHg) followed by Heart Failure (31.51 mmHg) and the sepsis group (19.46 mmHg). The results were found to be statistically significant (P < 0.05). CONCLUSION: NT-proBNP has high diagnostic accuracy in differentiating acute HF-related dyspnoea from pulmonary (COPD and ARDS)-related acute dyspnoea. The higher levels of ETCO2 help in diagnosing patients with COPD.

Keywords: NT PRO BNP, ETCO2, dyspnoea, lung USG

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Authors: Basma Hassabo, Sarah Ahmed, Aisha Hameed

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Aims and Objectives: To determine the incidence of maternal mortality amongst pregnant women with sickle cell disease (SCD) in the United Kingdom and to determine exact cause of death in these women. Background: SCD is caused by the ‘sickle’ gene and is characterized by episodes of severe bone pain and other complications like acute chest syndrome, chronic pulmonary hypertension, stroke, retinopathy, chronic renal failure, hepato-splenic crises, avascular bone necrosis, sepsis and leg ulcers. SCD is a continual cause of maternal mortality and fetal complications, and it comprises 1.5% of all Direct and Indirect deaths in the UK. Sepsis following premature rupture of membranes with ascending infection, post-partum infection and pre-labour overwhelming septic shock is one of its leading causes of death. Over the last fifty years of maternal mortality reports in UK, between 1 to 4 pregnant women died in each triennium. Material and Method: This is a retrospective study that involves pregnant women who died from SCD complications in the UK between 1952-2012. Data were collected from the UK Confidential Enquiries into Maternal Death and its causes between 1952–2012. Prior to 1985, exact cause of death in this cohort was not recorded. Results: 33 deaths reported between 1964 and 1984. 17 deaths were reported due to sickle cell disease between 1985 and 2012. Five women in this group died of sickle cell crisis, one woman had liver sequestration crisis, two women died of venous thromboembolism, two had myocardial fibrosis and three died of sepsis. Remaining women died of amniotic fluid embolism, SUDEP, myocardial ischemia and intracranial haemorrhage. Conclusion: The leading causes of death in sickle cell sick pregnant women are sickle cell crises, sepsis, venous thrombosis and thromboembolism. Prenatal care for women with SCD should be managed by a multidisciplinary team that includes an obstetrician, nutritionist, primary care physician, and haematologist. In every sick Sickle Cell woman Sickle Cell crises should be on the top of the list of differential diagnosis. Aggressive treatment of complications with low threshold to commence broad-spectrum antibiotics and LMWH contribute to better outcomes.

Keywords: incidence, maternal mortality, sickle cell disease (SCD), uk

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Authors: Nicholas Bayfield, Liam Bibo, Kaushelandra Rathore, Lucas Sanders, Mark Newman

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INTRODUCTION: Surgical pulmonary embolectomy is an established therapy for acute pulmonary embolism causing right heart dysfunction and haemodynamic instability. Massive intraoperative airway haemorrhage is a rare complication of pulmonary embolectomy. We present our institutional experience with massive airway haemorrhage complicating pulmonary embolectomy and discuss optimal therapeutic strategies. METHODS: A retrospective review of emergent surgical pulmonary embolectomy patients was undertaken. Cases complicated by massive intra-operative airway haemorrhage were identified. Intra- and peri-operative management strategies were analysed and discussed. RESULTS: Of 76 patients undergoing emergent or salvage pulmonary embolectomy, three cases (3.9%) of massive intraoperative airway haemorrhage were identified. Haemorrhage always began on weaning from cardiopulmonary bypass. Successful management strategies involved intraoperative isolation of the side of bleeding, occluding the affected airway with an endobronchial blocker, institution of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) and reversal of anticoagulation. Running the ECMO without heparinisation allows coagulation to occur. Airway haemorrhage was controlled within 24 hours of operation in all patients, allowing re-institution of dual lung ventilation and decannulation from ECMO. One case in which positive end-expiratory airway pressure was trialled initially was complicated by air embolism. Although airway haemorrhage was controlled successfully in all cases, all patients died in-hospital for reasons unrelated to the airway haemorrhage. CONCLUSION: Massive intraoperative airway haemorrhage during pulmonary embolectomy is a rare complication with potentially catastrophic outcomes. Re-perfusion alveolar and capillary injury is the likely aetiology. With a systematic approach to management, airway haemorrhage can be well controlled intra-operatively and often resolves within 24 hours. Stopping blood flow to the pulmonary arteries and support of oxygenation by the institution of VA ECMO is important. This management has been successful in our 3 cases.

Keywords: pulmonary embolectomy, cardiopulmonary bypass, cardiac surgery, pulmonary embolism

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Authors: Maha Salah Abdullah Ismail, Mahmoud M. Alsagheir, Mohammed Salah Abd Allah

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Acute respiratory distress syndrome (ARDS) is characterized by permeability pulmonary edema and refractory hypoxemia. Lung-protective ventilation is still the key of better outcome in ARDS. Prone position reduces the trans-pulmonary pressure gradient, recruiting collapsed regions of the lung without increasing airway pressure or hyperinflation. Prone ventilation showed improved oxygenation and improved outcomes in severe hypoxemic patients with ARDS. This study evaluates the effect of prone positioning on mechanically ventilated patients with ARDS. A quasi-experimental design was carried out at Critical Care Units, on 60 patients. Two tools were utilized to collect data; Socio demographic, medical and clinical outcomes data sheet. Results of the present study indicated that prone position improves oxygenation in patients with severe respiratory distress syndrome. The study recommended that use prone position in patients with severe ARDS, as early as possible and for long sessions. Also, replication of this study on larger probability sample at the different geographical location is highly recommended.

Keywords: acute respiratory distress syndrome, critical care, mechanical ventilation, prone position

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Authors: Joshua Abraham, Craig Wales

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Abstract—SIGN Guideline 122 recommends that all patients who are admitted to hospital are assessed for venous thromboembolism risk within 24 hours of admission. NHS Greater Glasgow and Clyde provide guidance on this in the form of a proforma. Patients are then subsequently prescribed either thrombo-embolic-deterrent stockings (TEDS)/low molecular weight heparin (LMWH) for the prevention of VTE based on their score. A retrospective casenote audit of a random sample of fifty oncology and trauma inpatients at the QEUH in December 2019 was performed. 90% of patients had a risk assessment conducted as evidenced by a completed proforma. In 78% of these patients, the proforma fully completed. Overall 94% of patients had some for of thromboprophylaxis prescribed in the form of TEDS or LMWH. A lack of 100% compliance against the given standards highlighted potential implications for patient safety, but also medico-legal ramifications for staff. Clinical judgement can only be relied upon if there is written documentation as evidence. Further staff education and the suggestion of a written prompt to the clerk-in documentation will hopefully improve compliance, whilst a repeat audit should demonstrate any improvement.

Keywords: Maxillofacial , Thromboembolism, Thromboprophylaxis , Prescription

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Authors: Nataliya V. Dolgushina, Elena A. Gorodnova, Olga S. Beznoshenco, Andrey Yu Romanov, Irina V. Menzhinskaya, Lyubov V. Krechetova, Gennady T. Suchich

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In patients with COVID-19, generalized hypercoagulability can lead to the development of severe coagulopathy. This event is accompanied by the development of a pronounced inflammatory reaction. The observational prospective study included 39 patients with mild COVID-19 and 102 patients with moderate and severe COVID-19. Patients were then stratified into groups depending on the risk of venous thromboembolism. vWF to ADAMTS-13 concentrations and activity ratios were significantly higher in patients with a high venous thromboembolism risks in patients with moderate and severe forms COVID-19.

Keywords: ADAMTS-13, COVID-19, hypercoagulation, thrombosis, von Willebrand factor

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Authors: Frazer Kirk, Matthew Yong, Peter Williams, Andrie Strobel

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Pulmonary valve papillary fibroelastoma is an exceedingly rare pathology. The experience and literature regarding them are largely anecdotal and based on sporadic, single case reports. Throughout their known history, two features remain salient that they are classically asymptomatic and found incidentally. The demographic profile of those affected is unclear, as reports regarding those affected are mixed, and there is no clear gender or age predominance, although there is some suggestion of a predisposition to affect females. Nor has there been a well-structured epidemiological study of the entity. Interestingly they are becoming more common on peri-mortum examination. Here-after we describe our experience with a symptomatic presentation of pulmonary papillary fibroelastoma masquerading as a pulmonary embolism and its subsequent assessment and management, with intraoperative photography and echocardiography for reference.

Keywords: cardiac tumor, pulmonary valve, fibroelastoma, cardiac surgery

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Authors: Kristel Dame Bañez Sumagaysay, Marie Victoria Cruz-javier

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The current subject is a case of a 21 year-old woman at 29 1/7 weeks of gestation with Pre-B cell Acute Lymphoblastic Leukemia who was admitted to the coronary care unit (CCU) of the St. Luke’s Medical Center-Global City for Severe Acute Respiratory Distress Syndrome (ARDS) secondary to hospital-acquired pneumonia secondary to pneumocystis jiroveci; central line-associated bloodstream infection (E. aerogenes). She presented with chronic hypoxemia caused by Pulmonary edema, probably secondary to heart failure secondary to cardiomyopathy chemotherapy-induced. Due to worsening feto-maternal status, extracorporeal membrane oxygenation (ECMO) for respiratory support was instituted, and an elective cesarean section was done due to multiple maternal factors and deteriorating health status under total intravenous anesthesia assisted by veno-venous extracorporeal membrane oxygenation. She delivered a live preterm newborn male, APGAR Score: 1, 0, 0, birth weight 985 grams, birth length: 40.5cm, small for gestational age.

Keywords: extracorporeal membrane oxygenation, pre-b cell acute lymphoblastic leukemia, severe acute respiratory distress syndrome, ethical dilemmas

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Authors: Vivek Ku, A. K. Janmeja, D. Aggarwal, R. Gupta

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Purpose: Pulmonary rehabilitation plays a key role in management of chronic lung diseases. However, pulmonary rehabilitation is an underused modality in the management of interstitial lung disease (ILD). This is because limited information is available in literature and no data is available from India on this issue so far. The study was carried out to evaluate the role of pulmonary rehabilitation on respiratory parameters in ILD patients. Methods: The present study was a prospective randomized non-blind case control study. Total of 40 ILD patients were randomized into 2 groups of 20 patients each viz ‘pulmonary rehabilitation group’ and ‘control group’. Pulmonary rehabilitation group underwent 8 weeks pulmonary rehabilitation (PR) along with medical management as per guidelines and the control group was advised only medical management. Results: Mean age in case group was 59.15 ± 10.39 years and in control group was 62.10 ± 14.54 years. The case and the control groups were matched for age and sex. Mean MRC grading at the end of 8 weeks showed significant improvement in the case group as compared to control group (p= 0.011 vs p = 0.655). Similarly, mean St. George Respiratory Questionnaire (SGRQ) score also showed significant improvement in pulmonary rehabilitation group at the end of the study (p= 0.001 vs p= 0.492). However, FEV1 and FVC had no significant change in the case and control group. Similarly, blood gases also did not show any significant difference in the group. Conclusion: Pulmonary rehabilitation improves breathlessness and thereby improves quality of life in the patients suffering from ILD. However, the pulmonary function values and blood gases are unaffected by pulmonary rehabilitation. Clinical Implications: Further large scale multicentre study is needed to ascertain the association.

Keywords: ILD, pulmonary rehabilitation, quality of life, pulmonary functions

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Authors: Anjelika Kremer, Irina Nachimov, Dan Justo

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Background: C-reactive protein (CRP) serum levels are commonly measured in hospitalized patients. Elevated admission CRP serum levels and in-hospital mortality has been seldom studied in the general population of elderly patients admitted to the acute Geriatrics department. Methods: A retrospective cross-sectional study was conducted at a tertiary medical center. Included were all elderly patients (age 65 years or more) admitted to a single acute Geriatrics department from the emergency room between April 2014 and January 2015. CRP serum levels were measured routinely in all patients upon the first 24 hours of admission. A logistic regression analysis was used to study if admission CRP serum levels were associated with in-hospital mortality independent of age, gender, functional status, and co-morbidities. Results: Overall, 498 elderly patients were included in the analysis: 306 (61.4%) female patients and 192 (38.6%) male patients. The mean age was 84.8±7.0 years (median: 85 years; IQR: 80-90 years). The mean admission CRP serum levels was 43.2±67.1 mg/l (median: 13.1 mg/l; IQR: 2.8-51.7 mg/l). Overall, 33 (6.6%) elderly patients died during the hospitalization. A logistic regression analysis showed that in-hospital mortality was independently associated with history of stroke (p < 0.0001), heart failure (p < 0.0001), and admission CRP serum levels (p < 0.0001) – and to a lesser extent with age (p = 0.042), collagen vascular disease (p=0.011), and recent venous thromboembolism (p=0.037). Receiver operating characteristic (ROC) curve showed that admission CRP serum levels predict in-hospital mortality fairly with an area under the curve (AUC) of 0.694 (p < 0.0001). Cut-off value with maximal sensitivity and specificity was 19.7 mg/L. Conclusions: Admission CRP serum levels may be used to predict in-hospital mortality in the general population of elderly patients admitted to the acute Geriatrics department.

Keywords: c-reactive protein, elderly, mortality, prediction

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Authors: N. Anand, P. S. Nayyer, V. Rana, S. Verma

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Background: Diabetes mellitus is a group of disorders characterized by hyperglycemia and associated with microvascular and macrovascular complications. Among the lesser known complications is the involvement of respiratory system. Changes in pulmonary volume, diffusion and elastic properties of lungs as well as the performance of the respiratory muscles lead to a restrictive pattern in lung functions. The present study was aimed to determine the changes in various parameters of pulmonary function tests amongst patients with Type 2 Diabetes Mellitus and also try to study the effect of duration of Diabetes Mellitus on pulmonary function tests. Methods: It was a cross sectional study performed at Dr Baba Saheb Ambedkar Hospital and Medical College in, Delhi, A Tertiary care referral centre which included 200 patients divided into 2 groups. The first group included diagnosed patients with diabetes and the second group included controls. Cases and controls symptomatic for any acute or chronic Respiratory or Cardiovascular illness or a history of smoking were excluded. Both the groups were subjected to spirometry to evaluate for the pulmonary function tests. Result: The mean Forced Vital Capacity (FVC), Forced Expiratory Volume in first second (FEV1), Peak Expiratory Flow Rate(PEFR) was found to be significantly decreased ((P < 0.001) as compared to controls while the mean ratio of Forced Expiratory Volume in First second to Forced Vital Capacity was not significantly decreased( p>0.005). There was no correlation seen with duration of the disease. Conclusion: Forced Vital Capacity (FVC), Forced Expiratory Volume in first second (FEV1), Peak Expiratory Flow Rate(PEFR) were found to be significantly decreased in patients of Diabetes mellitus while ratio of Forced Expiratory Volume in First second to Forced Vital Capacity (FEV1/FVC) was not significantly decreased. The duration of Diabetes mellitus was not found to have any statistically significant effect on Pulmonary function tests (p > 0.005).

Keywords: diabetes mellitus, pulmonary function tests, forced vital capacity, forced expiratory volume in first second

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Authors: Hendra Wibowo, Suprayitno Wardoyo, Dhama Shinta

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Introduction: Pediatric pulmonary tuberculosis (TB) incidence was increasing, with many undetected cases. In complicated TB, treatment should consist of returning pulmonary function, preventing further complications, and eliminating bacteria. Complicated TB management was still controversial, and surgery was one of the treatments that should be evaluated in accordance with its role in the treatment of complicated TB. Method: This study was an evidence-based case report. The database used for the literature search were Cochrane, Medline, Proquest, and ScienceDirect. Keywords for the search were ‘primary pulmonary tuberculosis’, ‘surgery’, ‘lung resection’, and ‘children’. Inclusion criteria were studies in English or Indonesian, with children under 18 years old as subject, and full-text articles available. The assessment was done according to Oxford Centre for evidence-based medicine 2011. Results: Six cohort studies were analyzed. Surgery was indicated for patients with complicated TB that were unresponsive towards treatment. It should be noted that the experiments were done before the standard WHO antituberculosis therapy was applied; thus, the result may be different from the current application. Conclusion: Currently, there was no guideline on pulmonary resection. However, surgery yielded better mortality and morbidity in children with complicated pulmonary TB.

Keywords: pediatric, pulmonary, surgery, therapy, tuberculosis

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Authors: Naser Shagerdi Esmaeli, Mohsen Hamidpour

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Purposes: The activation of coagulation in patients with cancer contributes significantly to morbidity and mortality rates and may play a fundamental role in the host response to growing tumor’s. Patients with cancer are clearly at high risk for the development of venous thromboembolism (VTE), particularly during chemotherapy and surgery. This situation is aggravated by the use of venous access catheters and possibly growth factors. Methods: Data derived from large, randomized, controlled trials have been used to determine the true incidence of this complication of cancer and its treatment. The incidence based on the analyses of these randomized controlled trials varies from 1% for limited stage patients with breast cancer treated with tamoxifen to 60% for patients with any type of cancer who are subjected to orthopedic surgery and do not receive prophylactic therapy. Results: In view of the morbidity and mortality attributable to VTE in cancer, widespread utilization of prophylactic anticoagulation therapy, which has proven safe and effective in a variety of situations, should be considered. While migratory thrombophlebitis is a clear indicator of an underlying neoplasm, the risk of cancer in patients with the more typical form of VTE has been the subject of intense debate over recent years. Conclusion: Some investigators have suggested that the relative risk of being diagnosed with occult cancer within six months of an episode of VTE (particularly recurrent VTE) could be up to 10-fold. However, the cost-effectiveness of aggressive screening for cancer in patients with VTE has not yet been defined adequately.

Keywords: venous thromboembolism, malignancy, cancer, tumor, heparin

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Authors: Diana Islam, Juan Fang, Vito Fanelli, Bing Han, Julie Khang, Jianfeng Wu, Arthur S. Slutsky, Haibo Zhang

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Introduction: MSC delivery in preclinical models of ARDS has demonstrated significant improvements in lung function and recovery from acute injury. However, the role of MSC delivery in ARDS associated pulmonary fibrosis is not well understood. Some animal studies using bleomycin, asbestos, and silica-induced pulmonary fibrosis show that MSC delivery can suppress fibrosis. While other animal studies using radiation induced pulmonary fibrosis, liver, and kidney fibrosis models show that MSC delivery can contribute to fibrosis. Hypothesis: The beneficial and deleterious effects of MSC in ARDS are modulated by the lung microenvironment at the time of MSC delivery. Methods: To induce ARDS a two-hit mouse model of Hydrochloric acid (HCl) aspiration (day 0) and mechanical ventilation (MV) (day 2) was used. HCl and injurious MV generated fibrosis within 14-28 days. 0.5x106 mouse MSCs were delivered (via both intratracheal and intravenous routes) either in the active inflammatory phase (day 2) or during the remodeling phase (day 14) of ARDS (mouse fibroblasts or PBS used as a control). Lung injury accessed using inflammation score and elastance measurement. Pulmonary fibrosis was accessed using histological score, tissue collagen level, and collagen expression. In addition alveolar epithelial (E) and mesenchymal (M) marker expression profile was also measured. All measurements were taken at day 2, 14, and 28. Results: MSC delivery 2 days after HCl exacerbated lung injury and fibrosis compared to HCl alone, while the day 14 delivery showed protective effects. However in the absence of HCl, MSC significantly reduced the injurious MV-induced fibrosis. HCl injury suppressed E markers and up-regulated M markers. MSC delivery 2 days after HCl further amplified M marker expression, indicating their role in myofibroblast proliferation/activation. While with 14-day delivery E marker up-regulation was observed indicating their role in epithelial restoration. Conclusions: Early MSC delivery can be protective of injurious MV. Late MSC delivery during repair phase may also aid in recovery. However, early MSC delivery during the exudative inflammatory phase of HCl-induced ARDS can result in pro-fibrotic profiles. It is critical to understand the interaction between MSC and the lung microenvironment before MSC-based therapies are utilized for ARDS.

Keywords: acute respiratory distress syndrome (ARDS), mesenchymal stem cells (MSC), hydrochloric acid (HCl), mechanical ventilation (MV)

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Authors: Shanza Akram, Sameen Toor, Heba Harb Abu Alkass, Zainab Abdulsalam Altaha, Sara Taha Abdulla, Saleem Imran

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Acute pulmonary embolism (PE) is a common disease and can be fatal. The clinical presentation is variable and nonspecific, making accurate diagnosis difficult. Testing patients with suspected acute PE has increased dramatically. However, the overuse of some tests, particularly CT and D-dimer measurement, may not improve care while potentially leading to patient harm and unnecessary expense. CTPA is the investigation of choice for PE. Its easy availability, accuracy and ability to provide alternative diagnosis has lowered the threshold for performing it, resulting in its overuse. Guidelines have recommended the use of clinical pretest probability tools such as ‘Wells score’ to assess risk of suspected PE. Unfortunately, implementation of guidelines in clinical practice is inconsistent. This has led to low risk patients being subjected to unnecessary imaging, exposure to radiation and possible contrast related complications. Aim: To study the diagnostic yield of CT PA, clinical pretest probability of patients according to wells score and to determine whether or not there was an overuse of CTPA in our service. Methods: CT scans done on patients with suspected P.E in our hospital from 1st January 2014 to 31st December 2014 were retrospectively reviewed. Medical records were reviewed to study demographics, clinical presentation, final diagnosis, and to establish if Wells score and D-Dimer were used correctly in predicting the probability of PE and the need for subsequent CTPA. Results: 100 patients (51male) underwent CT PA in the time period. Mean age was 57 years (24-91 years). Majority of patients presented with shortness of breath (52%). Other presenting symptoms included chest pain 34%, palpitations 6%, collapse 5% and haemoptysis 5%. D Dimer test was done in 69%. Overall Wells score was low (<2) in 28 %, moderate (>2 - < 6) in 47% and high (> 6) in 15% of patients. Wells score was documented in medical notes of only 20% patients. PE was confirmed in 12% (8 male) patients. 4 had bilateral PE’s. In high-risk group (Wells > 6) (n=15), there were 5 diagnosed PEs. In moderate risk group (Wells >2 - < 6) (n=47), there were 6 and in low risk group (Wells <2) (n=28), one case of PE was confirmed. CT scans negative for PE showed pleural effusion in 30, Consolidation in 20, atelactasis in 15 and pulmonary nodule in 4 patients. 31 scans were completely normal. Conclusion: Yield of CT for pulmonary embolism was low in our cohort at 12%. A significant number of our patients who underwent CT PA had low Wells score. This suggests that CT PA is over utilized in our institution. Wells score was poorly documented in medical notes. CT-PA was able to detect alternative pulmonary abnormalities explaining the patient's clinical presentation. CT-PA requires concomitant pretest clinical probability assessment to be an effective diagnostic tool for confirming or excluding PE. . Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered. Combining Wells scores with clinical and laboratory assessment may reduce the need for CTPA.

Keywords: CT PA, D dimer, pulmonary embolism, wells score

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Authors: Santony Santony, Teguh Rahayu Sartono, Iin Noor Chozin

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Introduction: Pneumonia is acute inflammation on lung parenchyma which is caused by bacteria, virus, fungi, or parasite. In Indonesia, Pneumonia is among the ten inpatient cases. Length of stay is related to the increased morbidity rate, nosocomial infection, and costs. The aim of this study is to assess the effect of pulmonary rehabilitation on the difference in length of stay and the level of Interleukin 6 (IL-6) as an inflammation biomarker for community-acquired pneumonia (CAP) patients in non-intensive rooms. Therefore, pulmonary rehabilitation as adjunctive therapy can be routinely exercised in order to shorten the length of stay, along with the decrease in IL-6 level. Methods: This study was conducted from May to October 2019 at Saiful Anwar General Hospital, Malang. 40 community-acquired pneumonia patients in non-intensive rooms were divided into two groups. 20 patients in the treatment group and 20 patients in the control group, all of them were selected through both inclusion and exclusion criteria. This study used simple consecutive random sampling. In the treatment group, pulmonary rehabilitation performed was composed of breathing exercise, effective coughing technique, clapping (percussion), postural drainage, as well as respiratory muscle training using incentive spirometry device. Pulmonary rehabilitation was conducted twice over five days with a minimum duration of 15 minutes. Blood samples were taken both on the first and the fifth day of the treatment to measure IL-6 level as an inflammation biomarker. Result: For the treatment group, the length of stay was 5.35 days whereas the control group 7.6 days. It can be seen that the treatment group had a shorter length of stay by 2.25 days (P<0,001). The IL-6 level on the first day for the treatment group was 36.27 pg/ml, whereas on the fifth day was 34.36 pg/ml. There was a decrease in IL-6 level on the fifth day of treatment even though it was not statistically significant (P=0.628). IL-6 level on the control group for the first day was 67.76 pg/ml, and after the fifth day, the level decreased to 54.43 pg/ml. There seemed to be a decrease in the IL-6, but it was not statistically significant (P=0.502). On the fifth day, the treatment group showed an average IL-6 level of 34.36 pg/ml. This value was lower than that of the control group which did not receive pulmonary rehabilitation having an IL-6 level of 54.43 pg/ml, even though it was not statistically significant (p=0.221). Conclusion: This study concluded that pulmonary rehabilitation as an adjunctive therapy shortened length of stay by 2.25 days for community-acquired pneumonia patients in a non-intensive room. Both groups experienced a decrease in IL-6 level on the fifth day in comparison with the first day even though it was not statistically significant P>0,05. IL-6 level as an inflammation biomarker decreased on the fifth day of treatment which was in accordance with improvement on pneumonia patients.

Keywords: community-acquired pneumonia, interleukin-6, length of stay, pulmonary rehabilitation

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Authors: Masashi Kanazawa, Takaaki Nakano, Masaaki Takemoto, Tomonori Imamura, Mamiko Sugimura, Toshitaka Ito

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Introduction: We experienced a massive disaster due to inhalation of water-soluble paint. Sixteen patients were brought to our emergency room, and pulmonary edema was revealed on the CT images of 12 cases. Purpose: Transition of chest CT-scan findings in cases with pulmonary edema was examined. Method: CT-scans were performed on the 1st, 2nd, 5th, and 19th days after the inhalation event. Patients whose pulmonary edema showed amelioration or exacerbation were classified into the improvement or the exacerbation group, respectively. Those with lung edema findings appearing at different sites after the second day were classified into the changing group. Results: Eight, one and three patients were in the improvement, exacerbation and changing groups, respectively. In all cases, the pulmonary edema had disappeared from CT images on the 19th day after the inhalation event. Conclusion: Inhalation of water-soluble paints is considered to be relatively safe. However, our observations in these emergency cases suggest that, even if pulmonary edema is not severe immediately after the exposure, new lesions may appear later and existing lesions may worsen. Follow-up imaging is thus necessary for about two weeks.

Keywords: CT scan, intoxication, pulmonary edema, water-soluble paint

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Authors: Nicholas Marinus Batt, Angus Radford, Khaled Saraya

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Pulmonary Embolus Severity Index (PESI) score is a well-validated decision-making score grading mortality rates (MR) in patients with a suspected or confirmed diagnosis of pulmonary embolism (PE) into 5 classes. Thirty and 90 days MR in class I and II are lower allowing the treatment of these patients as outpatients. In a London District General Hospital (DGH) with mixed ethnicity and high disease burden, we looked at MR at 1, 3, and 7 days of all PESI score classes. Our pilot study of 112 patients showed MR of 0% in class I, II, and III. The current study includes positive Computed Tomographic Scans (CT scans) for PE over the following three years (total of 555). MR was calculated for all PESI score classes at 1, 3 & 7 days. Thirty days MR was additionally calculated to validate the study. Our initial results so far are in line with our pilot studies. Further subgroup analysis accounting for the local co-morbidities and disease burden and its impact on the MR will be undertaken.

Keywords: Pulmonary Embolism (PE), Pulmonary Embolism Severity Index (PESI) score, mortality rate (MR), CT pulmonary artery

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Authors: Nouf Al Harthi

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Venous thromboembolism (VTE) is one of the most common causes of hospital-related deaths in critically ill patients. Guidelines recommended VTE prophylaxis with standardized, fixed doses for most patients. The underweight population has limited data to guide the appropriate drug and dosing regimen. The aim of this study was to describe the pattern of VTE prophylaxis dose regimens for underweighted critically ill adult patients and the prevalence of associated VTE and bleeding. This study is a retrospective cohort study, conducted in King Abdulaziz Medical City, Saudi Arabia. It included all critical patients admitted to the intensive care units and were above 14 years old with weight less than 50 kg or BMI of 18.5 kg/m2 or less and were on heparin as VTE prophylaxis for more than 72 hours from January 2016 until January 2020. After screening 270 patients, only 40 patients were included in this study according to our inclusion and exclusion criteria. Only 6 patients (15%) received VTE prophylaxis as an adjusted dose of heparin 2500 U Q12, while the rest of the patients were taking standard dosing of heparin, 5000 U Q12 was given to 21 (52.50%) patients and 5000 U Q8 was given to 13 (32.50%) patients. None of the adjusted doses developed any complications such as VTE or bleeding. There was no significant difference compared with the standard dose group. This study focused on describing the pattern of heparin doses as VTE prophylaxis in underweight patients. We also compared the standard dosing and adjusted dosage of VTE prophylaxis on underweight patients and any complications. There was no significant difference in the complication’s outcome or benefits between the two groups.

Keywords: venous thromboembolism prophylaxis, heparin, underweight patients, adult, critical care units

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Authors: Hyuk-Hoon Kim, Young Gi Min

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Background: Acute poisoning is the common cause of morbidity and mortality. Characteristics of acute poisoning differ between countries. While other countries operate the database system for poisoning, Korea has not collected the database for acute poisoning. Distribution of incidence of acute poisoning depending on the types of materials have also not studied in Korea. Our aims are to evaluate the etiologic and demographic characteristics of acute poisoning cases and to obtain up-to-date information on acute poisonings. Method: We retrospectively recorded cases of acute poisoning from eight emergency departments of second level or university hospitals from different cities in Gyeonggi province in Korea from April 2006 and March 2015. The distributions of incidence of acute poisoning depending on the types of materials are mapped by geographic information system. Result: A total of 3,449 poisoned cases were analyzed. Mean estimated age of patients was 39.56 ± 22.40 years. Mean male to female ratio of patients was 1:1.4. Mean proportion of intentional poisoning was 57.9%. Common materials are benzodiazepine (16.6%), carbon monoxide (10.5%), pesticide (8.1%) and zolpidem (7.1%) Common route of exposure is ingestion (79.5%) and followed by inhalation (16.5%). Common treatment methods are gastric lavage (20%) and activated charcoal (30%). Most cases had uneventful recovery; 61.4% were treated as outpatients and 0.1% of the poisoning resulted in death in ER. Conclusion: Even though the cases enrolled in our study is not the overall cases of acute poisoning in Korea, our study could be the basis of countermeasures for analysis and prevention of acute poisoning in Korea.

Keywords: acute poisoning, emergency department, epidemiology, Korea

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Authors: Ratchadaporn Ungcharoen, Lily Ingsrisawang

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Capture-recapture methods are popular techniques for indirect estimation the size of wildlife populations and the completeness of cases in epidemiology and social sciences. The aim of this study was to estimate the completeness of pulmonary tuberculosis cases confirmed by two sources of hospital registrations and surveillance systems in 2013 in Nakhon Pathom province, Thailand. Several estimators of population size were considered: the Lincoln-Petersen estimator, the Chapman estimator, the Chao’s lower bound estimator, the Zelterman’s estimator, etc. We focus on the Chapman and Chao’s lower bound estimators for estimating the completeness of pulmonary tuberculosis from two sources. The retrieved pulmonary tuberculosis data from two sources were analyzed and bootstrapped for 30 samples, with 241 observations from source 1 and 305 observations from source 2 per sample, for additional exploration of the completeness of pulmonary tuberculosis. The results from the original data show that the Chapman’s estimator gave the estimation of a total 360 (95% CI: 349-371) pulmonary tuberculosis cases, resulting in 57% estimated completeness cases. But the Chao’s lower bound estimator estimated the total of 365 (95% CI: 354-376) pulmonary tuberculosis cases and its estimated completeness cases was 55.9%. For the results from bootstrap samples, the Chapman and the Chao’s lower bound estimators gave an estimated 347 (95% CI: 309-385) and 353 (95% CI: 315-390) pulmonary tuberculosis cases, respectively. If for two sources recoding systems are available, record-linkage and capture-recapture analysis can be useful for estimating the completeness of different registration system. Both Chapman and Chao’s lower bound estimator approaches produce very close estimates.

Keywords: capture-recapture, Chao, Chapman, pulmonary tuberculosis

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Authors: Hossein Barri Ghazani

Abstract:

Transfusion-related acute lung injury is the main reason of transfusion-related death, and it’s assigned to white blood cell reactive antibodies present in the blood product (anti-HLA class I and class II or anti granulocyte antibodies). TRALI may occur in the COVID-19 patients who are treated by convalescent plasma. The rate of TRALI’s reactions is the same in both males and females and can happen in all age groups. TRALI’s occurrence is higher for people who receive plasma from female donors because the parous female donors have multiple HLA antibodies in their plasma. Patients with chronic liver disease have an augmented risk of transfusion-related acute lung injuries from plasma containing blood products like FFP and PRP. The condition of TRALI suddenly starts with a non‐cardiogenic pulmonary Edema, often accompanied by marked systemic hypovolemic and hypotension. The conditions occur during or within a few hours of transfusion. Chest X-ray shows a nodular penetration or bats’ wing pattern of Edema which can be seen in acute respiratory distress syndrome as well. TRALI can occur with any type of blood products and can occur with as little as one unit. The blood donor center should be informed of the suspected TRALI reactions when the symptoms of TRALI are observed. After a review of the clinical data, the donors must be screened for granulocyte and HLA antibodies. The diagnosis and management of TRALI is not simple and is best done with a professional team and a specialty skilled nurse experienced with the upkeep of these patients.

Keywords: TRALI, transfusion-related death, anti-granulocyte antibodies, anti-HLA antibodies, COVID-19

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Authors: Adnan Sahin, Ufuk Uylas, Ercument Pasaoglu, Tarik Caga, Enver Ihtiyar, Serdar Erkasap, Ersin Ates, Fatih Yasar

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Background: In this study, it was evaluated the demographic features, etiological factors and the management of acute pancreatitis. Methods: 106 patient hospitalized due to acute pancreatitis were retrospectively examined from 1 January 2015 to 31 December 2015 in Department of General Surgery of ESOGUMF. The data of gender, signs and symptoms, etiological factors, WBC, AST, ALT, Amilase, USG and CT findings treatment options ERCP, and complications, mortality rate were analysed. Results: The mean age of patients were 58.8 (53 men and 53 women). The causes of acute pancreatitis were as follows: gallbladder stone was 89, hyperlipidemia was 5 and idiopathic were 16 patients. Severe pancreatitis was developed in 16 patients in the biliary pancreatitis group and ERCP was performed. Cholecystectomy was performed to all biliary pancreatitis group patients after acute pancreatitis subside. The mean hospital stay period was 9.33 (2-37) day. Discussion and conclusion: Severe acute pancreatitis is a mortal disease. The most common etiological cause of acute pancreatitis is biliary origin. The first line treatment modality of acute pancreatitis is medical. Cholecystectomy should be planned to the all-biliary caused acute pancreatitis patients after the attack subside. ERCP is a useful treatment modality in the case of clinical worsening and suspicion of acute cholangitis. ERCP procedure used 16 patients in our series and these patients have a good morbidity and mean hospital period is lower than the others. We suppose that ERCP procedure should be planned selectively and conservatively.

Keywords: acute pancreatitis, ERCP, morbidity, treatment

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Authors: Theo Welch

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Background: Gamma-hydroxybutyrate (GHB) is a depressant of the central nervous system with euphoric effects. It is being increasingly used recreationally in the United Kingdom (UK) despite associated morbidity and mortality. Due to the lack of evidence, healthcare professionals remain unsure as to the optimum management of GHB acute toxicity. Methods: A literature review was undertaken of its pharmacology and the emergency management of its acute toxicity.Findings: GHB is inexpensive and readily available over the Internet. Treatment of GHB acute toxicity is supportive. Clinicians should pay particular attention to the airway as emesis is common. Intubation is required in a minority of cases. Polydrug use is common and worsens prognosis. Conclusion: An inexpensive and readily available drug, GHB acute toxicity can be difficult to identify and treat. GHB acute toxicity is generally treated conservatively. Further research is needed to ascertain the indications, benefits, and risks of intubating patients with GHB acute toxicity. instructions give you guidelines for preparing papers for the conference.

Keywords: GHB, gamma-hydroxybutyrate, prehospital, emergency, toxicity, management

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Authors: Arthi Ganapathy, Rati Tandon, Saroj Kaler

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Introduction: A thorough knowledge of variations in lung anatomy is of prime significance during surgical procedures like lobectomy, pneumonectomy, and segmentectomy of lungs. The arrangement of structures in the lung hilum act as a guide in performing such procedures. The normal pattern of arrangement of hilar structures in the right lung is eparterial bronchus, pulmonary artery, hyparterial bronchus and pulmonary veins from above downwards. In the left lung, it is pulmonary artery, principal bronchus and pulmonary vein from above downwards. The arrangement of hilar structures from anterior to posterior in both the lungs is pulmonary vein, pulmonary artery, and principal bronchus. The bronchial arteries are very small and usually the posterior most structures in the hilum of lungs. Aim: The present study aims at reporting the variations in hilar anatomy (arrangement and number) of lungs. Methodology: 75 adult formalin fixed cadaveric lungs from the department of Anatomy AIIMS New Delhi were observed for variations in the lobar anatomy. Arrangement of pulmonary hilar structures was meticulously observed, and any deviation in the pattern of presentation was recorded. Results: Among the 75 adult lung specimens observed 36 specimens were of right lung and the rest of left lung. Seven right lung specimens showed only 2 lobes with an oblique fissure dividing them and one left lung showed 3 lobes. The normal pattern of arrangement of hilar structures was seen in 22 right lungs and 23 left lungs. Rest of the lung specimens (14 right and 16 left) showed a varied pattern of arrangement of hilar structures. Some of them showed alterations in the sequence of arrangement of pulmonary artery, pulmonary veins, bronchus, and others in the number of these structures. Conclusion: Alterations in the pattern of arrangement of structures in the lung hilum are quite frequent. A compromise in knowledge of such variations will result in inadvertent complications like intraoperative bleeding during surgical procedures.

Keywords: fissures, hilum, lobes, pulmonary

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Authors: Jamal Abdi

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This paper is largely a response/critique of Samuel P. Huntington´s Clash of Civilizations thesis. The overriding argument is that Huntington´s thesis is characterized by failure to distinguish between ´groups´ and ´categories´. Multinational civilizations overcoming their internal collective action problems, which would enable them to pursue a unified strategy vis-à-vis the West, is a rather foundational assumption in his theory. Without assigning sufficient intellectual attention to the processes through which multinational civilizations may gain capacity for concerted action i.e. become a group, he contended that the post-cold-war world would be shaped in large measure by interactions among seven or eight major civilizations. Thus, failure in providing a convincing analysis of multi-national civilizations´ transition from categories to groups is a significant weakness in Huntington´s clash theory. It is also suggested that so-called Islamic terrorism and the war on terror is not to be taken as an expression of presence of clash between a Western and an Islamic civilization, as terrorist organizations would be superfluous in a world characterized by clash of civilizations. Consequences of multinational civilizations becoming a group are discussed in relation to contemporary Western superiority.

Keywords: categories, civilizations, clash, groups, groupness

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Authors: Bambang Wispriyono, Satria Pratama, Haryoto Kusnoputranto, Faisal Yunus, Meliana Sari

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Introduction/objective: The impact of the development of motor vehicles is increasing the number of pollutants in the air. One of the substances that cause serious health problems is NO2. The health impacts arising from exposure to NO2 include pulmonary function impairment. The purpose of this study was to determine the relationship of NO2 exposure on the incidence of pulmonary function impairment. Methods: We are using a cross-sectional study design with 110 traffic police who were divided into two groups: exposed (police officers working on the highway) and the unexposed group (police officers working in the office). Election subject convenient sampling carried out in each group to the minimum number of samples met. Results: The results showed that the average NO2 in the exposed group was 18.72 ppb and unexposed group is 4.14 ppb. Pulmonary dysfunction on exposed and unexposed groups showed that FVC (Forced Vital Capacity) value are 88.68 and 90.27. And FEV1 (Forced Expiratory Volume in One) value are 94.9 and 95.16. Some variables like waist circumference, Body Mass Index, Visceral Fat, and Fat has associated with the incidence of Pulmonary Dysfunction (p < 0.05). Conclusion: Health monitoring is needed to decreasing health risk in Policeman.

Keywords: NO2, pulmonary dysfunction, police traffic, Jakarta

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Authors: Rojith K. Balakrishnan

Abstract:

Spontaneous tumour lysis syndrome is a constellation of electrolyte abnormalities and an acute renal failure which occurs in the setting of rapid cell turnover prior to the administration of cytotoxic chemotherapy. While spontaneous tumour lysis well-described in patients with Burkitt lymphoma, it is thought to occur less commonly in patients with other hematological malignancies. We present a case of forty-year-old female who presented with features of acute renal failure, on further evaluation turned out to be a newly diagnosed acute myeloid leukemia with spontaneous tumour lysis best of our knowledge only three cases of AML with spontaneous tumour lysis has reported world wide.

Keywords: AML, tumour lysis, renal failure, myeloid leukemia

Procedia PDF Downloads 253