Worsening Of Dyspnea Research Articles

Changes and prognostic impact of noninvasive myocardial work indices in patients undergoing transcatheter aortic valve implantation.

The prognostic significance of noninvasive myocardial work (MW) indices in patients undergoing transcatheter aortic valve implantation (TAVI) has not been adequately examined. We retrospectively selected 88 consecutive patients (mean age 79.9 ± 6.4 years, 40% males) with severe aortic stenosis scheduled for TAVI enrolled in the EffecTAVI registry. Exclusion criteria were prior valve surgery, atrial fibrillation, and left bundle branch block (LBBB) at baseline. Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) were measured by echocardiography at baseline and at 30 days. Accuracy of the noninvasive measures was assessed by invasive evaluation of MW. In the overall population, a significant reduction in GWI (2406 ± 567 vs. 2063 ± 515 mmHg% before and after TAVI respectively, P < 0.001), GCW (2783 ± 616 vs. 2380 ± 495 mmHg%, P < 0.001) and GWW (238 ± 203 vs. 186 ± 135 mmHg%, P = 0.015) was observed at 30 days after TAVI. GWE improved only in patients who did not develop left ventricular dyssynchrony due to new-onset LBBB or pacemaker implantation following TAVI. In a multivariable Cox-regression analysis, GWE after TAVI (hazard ratio 0.892, 95% confidence interval 0.81-0.97; P = 0.011) was the strongest predictor of adverse events (a composite of all-cause death, worsening of dyspnea, or rehospitalization for cardiovascular events) at 1-year follow-up. TAVI results in significant changes in MW indices, including an early decrease in GWI, GCW and GWW, and an improvement in GWE in patients without left ventricle dyssynchrony. A GWE equal or less than 92% at 30 days is indicative of poor clinical outcomes at 1 year.

Outcomes among patients with chronic obstructive pulmonary disease after recovery from COVID-19 infection of different severity

While studies have suggested increased risks of severe COVID-19 infection in chronic obstructive pulmonary disease (COPD), the persistent and delayed consequences of COVID-19 infection on patients with COPD upon recovery remain unknown. A prospective clinical study was conducted in Hong Kong to investigate the persistent and delayed outcomes of patients with COPD who had COVID-19 infection of different severity (mild-moderate COVID-19 and severe COVID-19), compared with those who did not. Chinese patients with COPD ≥ 40 years old were recruited from March to September 2021. They were prospectively followed up for 24.9 ± 5.0 months until 31st August 2023. The primary outcome was the deterioration in COPD control defined as the change in mMRC dyspnea scale. The secondary outcomes included the change in exacerbation frequency and non-COVID-19 respiratory mortality (including death from COPD exacerbation or bacterial pneumonia). 328 patients were included in the analysis. Patients with mild-moderate and severe COVID-19 infection had statistically significant increased risks of worsening of mMRC dyspnoea scale by increase in 1 score from baseline to follow-up with adjusted odds ratios of 4.44 (95% CI = 1.95–10.15, p < 0.001) and 6.77 (95% CI = 2.08–22.00, p = 0.001) respectively. Patients with severe COVID-19 infection had significantly increased risks of increase in severe COPD exacerbation frequency with adjusted odds ratios of 4.73 (95% CI = 1.55–14.41, p = 0.006) non-COVID-19 respiratory mortality from COPD exacerbation or pneumonia with adjusted hazard ratio of 11.25 (95% CI = 2.98–42.45, p < 0.001). After recovery from COVID-19, worsening of COPD control from worsening of dyspnea, increase in severe exacerbation frequency to non-COVID-19 respiratory mortality (COPD exacerbation and pneumonia) was observed among patients with severe COVID-19. Mild to moderate COVID-19 was also associated with symptomatic deterioration.

HEART FAILURE WITH PRESERVED EJECTION FRACTION (HFPEF) IN A PATIENT WITH RECENT TAVI AND NUMEROUS CORONARY FISTULAS OF THE LEFT CORONARY ARTERY DRAINING INTO THE VENTRICULAR CAVITY

Abstract Coronary fistula is a rare form of congenital heart disease and is defined as an abnormal connection between a coronary branch and a cardiac chamber or a large intrathoracic vessel without the interposition of the capillary circulation. The right coronary artery is the most common site of origin for coronary fistula. Other sites include the left anterior descending artery and left circumflex artery. The clinical presentation and the natural history can be extremely variable depending on the patient‘s age, fistula size, and anatomy. Small to medium–sized coronary fistulas may be asymptomatic. Large fistulas can manifest with angina pectoris due to myocardial ischemia secondary to the coronary steal phenomenon. Shunting through large fistulas can have hemodynamic consequences secondary to volume overload in the pulmonary or systemic circulation, leading to symptoms and signs of heart failure. We describe the case of an 83–year–old woman recently undergoing TAVI and suffering from primary myelofibrosis requiring periodic transfusions. Pre–TAVI coronary angiography showed coronary vessels free from significant hemodynamic lesions and multiple coronary–ventricular fistulas draining into the left ventricle. Total body aortic CT angiography did not reveal other abnormal vascular connections. One month after the aortic valve correction procedure, the patient presented with heart failure (HfpEF). At a recent follow–up visit, diuretic therapy was discontinued due to the successful correction of aortic valve disease and normal ejection fraction. Due to further anemization from the underlying hematologic condition, the patient underwent blood transfusion with worsening of dyspnea despite correction of hemoglobin levels. Discontinuation of diuretic therapy and transfusion of red blood cell units resulted in volume overload with worsening clinical condition. The presence of multiple coronary fistulas precluded an interventional approach, but therapeutic optimization and reintroduction of diuretic therapy restored the patient‘s hemodynamic compensation. Usually fistulas drain into the low–pressure venous circulation like right ventricle and right atrium. This case represents a rare instance of multiple left coronary fistulas draining into the left ventricle (only 3% of cases). Aortic valve correction may have further reduced left ventricular telediastolic pressures, worsening the shunt of coronary fistulas resulting in heart failure due to volume overload.

Patient education and rehabilitation after pulmonary thromboembolism

Persistent or worsening of dyspnea and limitation of physical activities in patients after an episode of acute pulmonary thromboembolism, reported in long-term studies, may subsequently be the main determinant of impaired quality of life. Physical rehabilitation and patient education after a thromboembolic event has not taken its place in the management of this group of patients. We set out to implement of patient education and the partially supervised physical rehabilitation program at home for patients after PE in the first 3 months after the acute event. The results of our study demonstrated the increase in functional capacity, the improvement of the quality of life, the reduction of the symptom of dyspnea. This article is part of the results of the study within the state project with the figure 20.80009.8007.28.

Long-term clinical course and outcomes of patients with microscopic polyangiitis-associated interstitial lung disease.

Background: Interstitial lung disease (ILD) is a significant complication associated with microscopic polyangiitis (MPA) that has a poor prognosis. However, the long-term clinical course, outcomes, and prognostic factors of MPA-ILD are not well defined. Hence, this study aimed to investigate the long-term clinical course, outcomes, and prognostic factors in patients with MPA-ILD. Methods: Clinical data of 39 patients with MPA-ILD (biopsy proven cases, n = 6) were retrospectively analyzed. High resolution computed tomography (HRCT) patterns were assessed based on the 2018 idiopathic pulmonary fibrosis diagnostic criteria. Acute exacerbation (AE) was defined as the worsening of dyspnea within 30days, with new bilateral lung infiltration that is not fully explained by heart failure or fluid overload and that does not have identified extra-parenchymal causes (pneumothorax, pleural effusion, or pulmonary embolism). Results: The median follow-up period was 72.0months (interquartile range: 44-117months). The mean age of the patients was 62.7years and 59.0% were male. Usual interstitial pneumonia (UIP) and probable usual interstitial pneumonia patterns on high resolution computed tomography were identified in 61.5 and 17.9% of the patients, respectively. During the follow-up, 51.3% of patients died, and the 5- and 10-year overall survival rates were 73.5% and 42.0%, respectively. Acute exacerbation occurred in 17.9% of the patients. The non-survivors had higher neutrophil counts in bronchoalveolar lavage (BAL) fluid and more frequent acute exacerbation than the survivors. In the multivariable Cox analysis, older age (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.01-1.14; p = 0.028) and higher BAL counts (HR, 1.09; 95% CI, 1.01-1.17; p = 0.015) were found to be the independent prognostic factors associated with mortality in patients with MPA-ILD. Conclusion: During the 6years-follow-up, about half of patients with MPA-ILD died and approximately one-fifth experienced acute exacerbation. Our results suggest that older age and higher BAL neutrophil counts mean poor prognosis in patients with MPA-ILD.

Pulmonary Embolism and Respiratory Deterioration in Chronic Cardiopulmonary Disease: A Narrative Review

Patients with chronic cardiopulmonary pathologies have an increased risk of developing venous thromboembolic events. The worsening of dyspnoea is a frequent occurrence and often leads patients to consult the emergency department. Pulmonary embolism can then be an exacerbation factor, a differential diagnosis or even a secondary diagnosis. The prevalence of pulmonary embolism in these patients is unknown, especially in cases of chronic heart failure. The challenge lies in needing to carry out a systematic or targeted diagnostic strategy for pulmonary embolism. The occurrence of a pulmonary embolism in patients with chronic cardiopulmonary disease clearly worsens their prognosis. In this narrative review, we study pulmonary embolism and chronic obstructive pulmonary disease, after which we turn to pulmonary embolism and chronic heart failure.

COVID-19-associated coagulopathy: a clinical case

Background. Comorbid patients with a new coronavirus disease (COVID-19) often have thrombosis or bleeding in different periods of the disease. Early diagnosis of these complications and adequate therapy of these patients are complicated due to the peculiarities of the disease in comorbidity. Anticoagulation regimens in patients with COVID-19 are still unclear. The protocol of efficacy and safety the intermediate or therapeutic dose of low-molecular-weight heparins is not clear and complete. It is very important to organize an individual approach for correction of the anticoagulants doses, taking into account the coagulation tests and the activity of inflammatory markers.Clinical case description. We report a 71-year-old white male with COVID-19 pneumonia. Acute respiratory distress syndrome and atrial fibrillation were diagnosed in ten days of the disease. Therapeutic anticoagulation was started upon the admission. As early as in the 20th day of the disease a gluteal hematoma developed. Hence, prophylactic regimen of anticoagulation was started, but the worsening of dyspnea at rest, decreasing in SpO2 values to 82% according to pulse oximetry, and thrombelastographic hypercoagulability were observed after two days of such anticoagulation treatment. The patient has been receiving daily low-molecular-weight heparins injections in therapeutic doses for the following two weeks, and then the doctors have switched him to new oral anticoagulants. Patient was discharged to continue ambulatory anticoagulant’s treatment.Conclusion. It is clear that the optimal choice of anticoagulation strategy in comorbid patients with concomitant COVID-19 remains challenging and requires randomized trials. Until the guidelines develop the effective anticoagulation strategy for various phenotypes of COVID-19 patients, the clinicians’ knowledge, experience and creative thinking will be apply to choose effective anticoagulant’s treatment on individual basis.

DELAYED ASPIRATION THROMBECTOMY OF SADDLE PULMONARY EMBOLISM IN A HEMODYNAMICALLY STABLE PATIENT

DELAYED ASPIRATION THROMBECTOMY OF SADDLE PULMONARY EMBOLISM IN A HEMODYNAMICALLY STABLE PATIENT

RISK FACTORS FOR ACUTE EXACERBATIONS OF HYPERSENSITIVITY PNEUMONITIS

TYPE: Abstract TOPIC: Diffuse Lung Disease PURPOSE: Acute exacerbations (AE) of Interstitial Lung Diseases are associated with bad outcomes. In Hypersensitivity Pneumonitis (HP), there is little evidence regarding factors associated with their development. METHODS: A retrospective analysis of 119 HP patients followed at our center between 2012-2017 was performed. AE was defined as worsening of dyspnea within a 30-day period, with new bilateral lung infiltration and no evidence of other causes of dyspnea, leading to hospitalization. RESULTS: A total of 15 (13.0%) patients developed AE of HP in a median 36 months follow-up. Patients with AE were younger (59.8 ± 10.0 years) than those without AE (69.2 ± 11.3years), p<0.01. Regarding lung function, patients with AE had lower FVC % (69.8 vs 85.7, p=0.024) and lower FEV1% (74.9 vs 90.3, p=0.032). Lower age, FVC%, FEV1% and exposure to mold/humidity were independent risk factors for development of AE in an univariate analysis (p<0.05). Patients who reported exposure to humidity/mold had a higher rate of AE (23.5% vs 9.0%, p=0.041). Exposure to humidity/mold remained a significant risk factor for AE even after adjusting for FVC%, FEV1% and age (OR 3.79, p=0.037). A total of 6 patients died during the exacerbation (40.0%). CONCLUSIONS: A worst lung function, lower age, and a patient report of exposure to humidity or molds were factors associated with the development of AE. This entity is associated with high in-hospital mortality. CLINICAL IMPLICATIONS: A better recognition of risk factors may enable strategies for early recognition and management of AE. An exposure etiologic factor identification can elucidate on strategies to avoid exacerbations. DISCLOSURE: Nothing to declare. KEYWORD: Hypersensitivity Pneumonitis

Linguistic Validation of the Japanese Version of the Multidimensional Dyspnea Profile and Relation to Physical Activity in Patients with COPD.

PurposeThis study aimed to develop a linguistically validated Japanese translation of the multidimensional dyspnea profile (MDP) and assess whether worsening of dyspnea’s sensory and affective domains during exercise had detrimental effects on physical activity in stable outpatients with chronic obstructive pulmonary disease (COPD).Materials and MethodsThe Japanese version of the MDP was prepared in collaboration with Mapi Research Trust (Lyon, France) after the approval of the developer. Physical activity was assessed using a 3-axis accelerometer. Dyspnea upon exertion was investigated using a 3-minute step test.ResultsThe Japanese version of the MDP was obtained and validated linguistically. Air-hunger was significantly associated with total calories from walking (r = − 0.47, p < 0.05), while anxiety and depression were significantly correlated with both the amount and intensity of physical activity (r = − 0.49, p < 0.05, and r = − 0.46, p < 0.05, respectively).ConclusionThe Japanese version of the MDP was suggested to reflect both pulmonary functions, ventilatory response during exercise, and intensity and amount of physical activity in patients with COPD.

Acute exacerbation of fibrotic hypersensitivity pneumonitis: incidence and outcomes

BackgroundPatients with fibrotic hypersensitivity pneumonitis (HP) show variable clinical courses, and some experience rapid deterioration (RD), including acute exacerbation (AE). However, little is known about AE in fibrotic HP. Here, we retrospectively examined the incidence, risk factors, and outcomes of AE in fibrotic HP.MethodsThe incidence rates of AE were calculated in 101 patients with biopsy-proven HP. AE was defined as the worsening of dyspnoea within 30 days, with new bilateral lung infiltration and no evidence of infection or other causes of dyspnoea.ResultsDuring follow-up (median: 30 months), 18 (17.8%) patients experienced AE. The 1, 3, and 5 year incidence rates of AE were 6.0, 13.6, and 22.8%, respectively. Lower diffusing capacity of the lung for carbon monoxide (DLCO) and a radiologic usual interstitial pneumonia (UIP)-like pattern were risk factors for AE. In-hospital mortality after AE was 44.4%. Median survival from diagnosis was significantly shorter in patients with AE (26.0 months) than in those with no-AE RD (55.0 months; p = 0.008) or no RD (not reached; p < 0.001). AE remained a significant predictor of all-cause mortality (hazard ratio, 8.641; 95% confidence interval, 3.388–22.040; p < 0.001) after adjustment for age, body mass index, lung function, lymphocyte levels in bronchoalveolar lavage fluid, and the presence of a UIP-like pattern.ConclusionsAE was not uncommon among patients with fibrotic HP and significantly affected prognosis. A lower DLCO value and radiologic UIP-like pattern at diagnosis were associated with the development AE in patients with fibrotic HP.

AB0413 HIGH-RESOLUTION COMPUTED TOMOGRAPHY FOR THE SCREENING, RE-SCREENING AND FOLLOW-UP OF SYSTEMIC SCLEROSIS RELATED INTERSTITIAL LUNG DISEASE: RESULTS OF A EUSTAR-SCTC SURVEY

Background:High-resolution computed tomography (HRCT) is the gold standard diagnostic test for Interstitial lung disease (ILD), a significant cause of morbidity and mortality in systemic sclerosis (SSc). Different algorithms have been proposed for the screening of SSc-ILD, including the use of pulmonary function tests (Forced Vital Capacity - FVC, Lung Diffusion of Carbone Monoxyde - DLCO). A prior survey reported that 50-66% of general rheumatologists and SSc experts ordered HRCT for ILD screening in newly diagnosed SSc patients (1).Objectives:Given the recent availability of on-label treatment for SSc-ILD (2), the publication of consensus recommendations for the identification of SSc-ILD (3) and recent awareness programs for the use of HRCT to detect SSc-ILD, we aimed to re-evaluate the use of HRCT for screening, re-screening and follow-up of SSc-ILD.Methods:An invitation was sent to the European Scleroderma Trials and Research (EUSTAR) and Scleroderma Clinical Trials Consortium (SCTC) members, also advertised through social media. Answers were recorded between Nov 25th and Dec 31st 2020. Questions were asked on the use of chest HRCT at baseline, the re-screening of patients with a negative baseline HRCT and the follow-up of HRCT positive SSc-ILD patients. When HRCT was not routinely requested, additional details were collected about the parameters guiding its use. The results of the survey were tested for association with geographical origin, medical specialty, working environment, SSc referral institute and scientific group membership of the responders, using Chi-squared test.Results:205/630 (32.5%) physicians replied to the survey. Participants were widely distributed in terms of geographical origin (130 Europe, 23 Asia, 23 North America, 31 other continents), medical specialty (156 rheumatology, 21 internal medicine, 14 clinical immunology, 14 other), working environment (176 University Hospital, 12 community hospital, 17 other), SSc dedicated clinic (179 referral and 26 non-referral) and scientific group membership (98 EUSTAR, 42 SCTC, 42 EUSTAR and SCTC, 23 not declared).At SSc diagnosis, 95.7% of responders would perform HRCT: 66.7% as routine screening for ILD (67,4% of SSc referral and 62% for non-referral physicians) and 29% for diagnostic purposes (among the latter, if crackles on auscultation – 92.5%, FVC&lt;80% predicted - 86.6%, FVC±DLCO relative decline reaching the current definition of ILD progression, 86.6% or dyspnea at rest/exercise - 85.1/83.3%).During follow-up, 78.8% of responders would repeat an HRCT in baseline negative cases: 20.3% as a yearly routine screening and 64.5% for diagnostic aims (decision on the latter group was more frequently driven by FVC±DLCO relative decline indicative of ILD progression– 90.6%, new onset or worsening of dyspnoea at rest/exercise – 80.5/86.6%, new onset or worsening of lung crackles on auscultation – 82.6%).Finally, 94.5% of responders would repeat a chest HRCT after SSc-ILD diagnosis: 36.8% as a yearly routine and 56.7% according to clinical evaluation (driven by new FVC±DLCO relative decline based ILD progression – 90.8%, new onset or worsening of dyspnoea at rest/exercise – 83.2/81.7%; 5.2% to evaluate treatment effects). We found no difference in the distribution of answers among groups.Conclusion:The use of baseline HRCT for the screening of SSc-ILD has slightly increased in non-referral and remained stable in referral centers compared to previous surveys, indicating that the implementation of guidelines might be successful and awareness programs should be continued. In addition, we provide new data on use of HRCT in re-screening and follow-up. The development of validated algorithms to further support the appropriate application of HRCT at follow-up is highly needed.

Trans-aortic Mitral Valve Repair and Aortic Valve Replacement with Rapid Deployment Prostheses in High Risk Patients

Objective: To report a case of trans-aortic mitral valve repair and aortic valve replacement with rapid deployment prosthesis in a high risk patient. Methods: A 79 year-old female underwent trans-aortic mitral valve repair and aortic valve replacement with rapid deployment prosthesis. Her past medical history revealed hypertension, COPD and diabetes. She was referred to our center for the worsening of dyspnea on exertion. Trans-thoracic echocardiogram showed a severe aortic regurgitation and moderate mitral regurgitation. The mechanism of mitral insufficiency was the chordal rupture of the scallop A2 while aortic valve was calcified. Ejection fraction was 45%. She was a very fragile patient with a intermediate surgical risk profile (Euroscore II: 6.6%). Results: After removing the calcified aortic valve, we carried out a trans-aortic mitral valve repair by cutting the two ruptured chords on A2 and performing an edge-to-edge plasty between A2 and P2. Afterwards, we implanted a rapid deployment aortic prosthesis. This approach allowed us to reduce the CPB and aortic cross clamp times. Post-operative TTE showed trivial mitral regurgitation and no aortic paravalvular leaks. The patient was in-hospital discharged by a week. Conclusions: In high risk patients suffering from mitro-aortic disease our approach could be safe and easy.

A DIAGNOSTIC DILEMMA: NORMAL D-DIMER IN A PATIENT WITH EXTENSIVE PULMONARY EMBOLISM

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The presentation of pulmonary embolism (PE) is very non-specific and carries a significant morbidity and mortality. Typically, D-dimer assay has a very high sensitivity and a negative predictive value of 99-100% in both low and moderate risk groups. We present a unique case of diagnosing extensive PE with deep vein thrombosis (DVT) in presence of a normal D-dimer. CASE PRESENTATION: A 69-year-old female with significant history of hypertension and diabetes presented with dry cough and worsening of dyspnea on exertion for four days. Patient denied chest pain, palpitations, fever, chills, diaphoresis, leg pain or swelling. Vitals showed a T 98.6, BP 112/64 mmHg, HR 56, RR 16, oxygen saturation of 90% on 3LPM of nasal canula. Physical exam, especially the pulmonary exam, was largely unremarkable. No swelling or pain in the lower extremities was noted. Laboratory findings including the metabolic panel, blood count, and a set of troponins were within normal limits. ECG showed a normal sinus rhythm, and a follow-up chest radiograph and a non-contrast CT scan of chest did not demonstrate any significant findings. Acute PE was ruled out since the D-dimer assay was normal and the pretest probability was low-moderate. Preliminary diagnosis of pulmonary hypertension was suspected and worked up. An echocardiogram showed severe pulmonary hypertension with elevated right ventricular systolic pressure in the setting of a normal LV ejection fraction. A ventilation perfusion scan was subsequently done to evaluate for CTEPH, and was overwhelmingly positive with a high probability of PE. A CT angiogram revealed extensive bilateral central and segmental PE. Doppler ultrasound of lower extremities revealed an acute non-occlusive DVT involving the left popliteal vein. Patient was subsequently started on anti-coagulants and the supplemental oxygen was continued prior to safe discharge. DISCUSSION: D-dimer assay is a highly sensitive test used in the evaluation of PE. It is a measure of monoclonal antibody to D-Dimer produced during the process of fibrinolysis. D-dimer has a half-life of 4-6 hours and stays elevated for about seven days. Once the clot organization and adherence begins, levels of D-dimer drop. As such, D-dimer levels correlate with the presence of fibrin clots. The assay can be falsely negative if the specimen is collected very early or later than 7 days of clot formation. Regardless, a negative assay should be able to safely rule out a large PE in low and moderate risk patients. A low d-dimer assay on presentation in light of an extensive PE/DVT makes our case unique. CONCLUSIONS: D-dimer assay usually provides excellent diagnostic yield while ruling out a PE/DVT. However, it remains prudent to consider the overall clinical presentation and go through a step by step approach to not miss a disease with a fatal potential such as a PE in our case. Reference #1: Dagkiran H, Atas R, Tomic I, Plachtzik C, Geisler T, Gawaz MP, Oberhoff M, Anger T. Severe Pulmonary Embolism with Negative D-Dimer-Testing. Journal of Cardiology and Therapy 2015; 2(1): 265-268 Available from: URL: http://www.ghrnet.org/index.php/jct/article/view/1033 Reference #2: Gupta RT, Kakarla RK, Kirshenbaum KJ, Tapson VF. D-dimers and efficacy of clinical risk estimation algorithms: sensitivity in evaluation of acute pulmonary embolism. AJR Am J Roentgenol. 2009;193(2):425-430 Reference #3: Le Gal G, Righini M, Roy P, et al. Value of D-Dimer Testing for the Exclusion of Pulmonary Embolism in Patients With Previous Venous Thromboembolism. Arch Intern Med. 2006;166(2):176 -180. doi:http://dx.doi.org/10.1001/archinte.166.2.176 DISCLOSURES: No relevant relationships by Richard Miller, source=Web Response No relevant relationships by Kinjal Patel, source=Web Response No relevant relationships by Rutwik Patel, source=Web Response No relevant relationships by Krunal Trivedi, source=Web Response

Efficacy of oral torasemide in dogs with degenerative mitral valve disease and new onset congestive heart failure: The CARPODIEM study.

BackgroundTorasemide is a potent loop diuretic with potential to treat congestive heart failure (CHF) in dogs.ObjectiveEvaluate the efficacy and safety of torasemide compared to furosemide in dogs with first occurrence of CHF caused by degenerative mitral valve disease (DMVD).AnimalsThree hundred and nineteen dogs with new onset CHF attributable to DMVD.MethodsDouble‐blinded randomized noninferiority study of PO torasemide vs furosemide in addition to standard CHF treatment. The primary efficacy criterion was decreased pulmonary edema and cough and no worsening of dyspnea or exercise tolerance at day 14. Secondary endpoints included clinical response at day 84 and time to death, euthanasia, or premature study withdrawal for cardiac reasons.ResultsTorasemide q24h (n = 161) was noninferior to furosemide q12h (n = 158); percentage of dogs meeting primary efficacy criterion at day 14 was similar between groups (torasemide, 74.4% [95% confidence interval (CI), 66.8%‐81.0%] vs. furosemide, 73.5% [95% CI, 65.7%‐80.4%]; risk ratio [RR], 1.01; 95% CI, 0.89‐1.15; P = .87). Efficacy at day 84 showed similar results (RR, 1.05; 95% CI, 0.88‐1.25; P = .6). Dogs receiving torasemide had a longer time to endpoint and were less than half as likely to experience death, euthanasia, or premature study withdrawal (hazard ratio, 0.36; 95% CI, 0.19‐0.65; P = .001) than dogs receiving furosemide at any time during the study.Conclusion and Clinical importanceTorasemide was noninferior to furosemide as first line PO treatment for new onset CHF caused by DMVD. Torasemide significantly decreased risk of cardiac‐related death or premature study withdrawal for cardiac reasons compared to furosemide.

Need for Pulmonary Screening in Rheumatoid Arthritis Patients: An Observational Study

Background: Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease characterized by articular and extra-articular involvement. The extra-articular involvement in RA is primarily manifested in pulmonary system characterized with pleurisy, airway diseases, nodular formations, and interstitial involvement. Aim: The aim was to assess the need of pulmonary screening in RA. Patients and Methods: A cross-sectional observational study was conducted on 122 patients who presented with respiratory difficulties and suspected RA. Initial screening for pulmonary involvement was done with physical assessment and pulmonary function tests (PFTs) followed with high-resolution computerized tomography (HRCT) scan. Health-related quality of life was assessed with pre–post 6-min walk test (6MWT) followed with dyspnea assessment and pulse oximetry. Results: Of the 122 patients screened, 33 were diagnosed with RA. The mean age was 40–50 years, was more common in women, and PFT showed both restrictive and obstructive pattern. Review of HRCT pattern of all patients showed nonspecific interstitial pneumonia pattern as the most common finding. Patients had desaturation after 6MWT and worsening of dyspnea. Conclusion: The degree of pulmonary involvement in RA is related to the duration of the disease. Clinical assessment, PFT, and 6MWT used in combination are cost-effective tools in early detection. HRCT provides a better understanding of the pattern of pulmonary involvement in RA.

Characteristics and prognosis of interstitial pneumonias complicated with pneumomediastinum.

The clinical characteristics and prognostic impact of complication with pneumomediastinum in patients with interstitial pneumonias (IPs) are not well studied due to the relatively limited nature of available reports. The purpose of this study was to clarify the characteristics and prognostic factors of IPs complicated with pneumomediastinum. Consecutive patients with IPs complicated with pneumomediastinum detected by computed tomography (CT) between July 1, 2011, and April 30, 2014 were retrospectively reviewed. Clinical data including symptoms associated with pneumomediastinum, laboratory data, lung function tests, treatments, and mortality were collected from medical records. Forty-five patients (25 males, 20 females), including 32 with idiopathic IP (IIPs) and 13 connective tissue disease-associated interstitial lung diseases (CTD-ILDs) were identified. The median age of onset of pneumomediastinum was 72 years (interquartile range [IQR] 68-79 years). The most common symptom associated with occurrence of pneumomediastinum was appearance or worsening of dyspnoea. No specific treatment was performed for most (84%) of the cases. The median period between occurrence and improvement of pneumomediastinum was 29 days (IQR 5-69 days). Multivariate analysis revealed that IIPs and no improvement of pneumomediastinum were associated with poor prognosis. Patients with IIPs complicated with pneumomediastinum and those without improvement of pneumomediastinum had poor prognosis.

Myofascia-dominant involvement on whole-body MRI as a risk factor for rapidly progressive interstitial lung disease in dermatomyositis

Rapidly progressive interstitial lung disease (RPILD) is a major cause of death in patients with DM. Although clinically amyopathic DM (CADM) represents risk for RPILD, the incidence rate of RPILD in patients with CADM varies widely. Whole-body (WB) MRI can reveal involvement of systemic muscle and myofascia. The objective of this study was to explore the risk factors for RPILD in patients with DM using WB-MRI. This retrospective study comprised 41 patients with DM who underwent WB-MRI before the initiation of treatment in our hospital. Muscular and myofascial signals were scored on 42 muscular groups. The myofascia/muscle ratio was calculated and used to define the relevance of myofascia-dominant involvement. RPILD was defined as worsening of dyspnoea, hypoxaemia and radiographic ILD/fibrosis within 3 months from the onset of respiratory symptoms. Among the 41 patients, 17 had CADM and 30 had ILD, including 10 patients with RPILD. All patients including those with CADM showed abnormal signal intensity in both muscle and myofascia (median score: 15 and 23, respectively). Muscle signal scores positively correlated with the serum creatine kinase level (r = 0.714; P<0.001). Patients with RPILD showed a significantly higher myofascia/muscle ratio than those without RPILD (1.929 vs 1.200; P=0.027). Logistic regression analysis identified higher myofascia/muscle ratio as independent risk factors for developing RPILD. Myofascia-dominant involvement was defined and appreciated in patients with DM using WB-MRI. This may be one of the risk factors for RPILD.

A Study of Indications and Outcome of Non-Invasive Ventilation in Respiratory Care Unit of a Tertiary Care Hospital in Eastern India

Introduction: Patients with Acute Respiratory Failure (ARF) can be ventilated noninvasively through Bi-Level Positive Pressure Ventilation (Bi-PAP). The proper timing, indications and outcome of Non-invasive Ventilation (NIV) have been evaluated worldwide by many investigators. Optimum selection of patients leads to better outcome reducing need for invasive ventilation; while the reverse can cause inappropriate delay in intubation leading to clinical deterioration, increased morbidity and mortality. Aim: To evaluate the indications and outcome, with relevant factors in all patients requiring NIV in Respiratory Care Unit (RCU) of a teaching hospital. Materials and Methods: This was a hospital-based observational study conducted from April 2016 to March 2017. After ethical approval, all patients who were put on NIV in RCU of the institution during the period of one year were enlisted. Evaluation by history, detailed clinical examination and necessary investigations including blood count, biochemistry, Arterial Blood Gas (ABG) analysis, oxymetry, microbiological investigations, imaging of thorax etc., was done. Examination and investigations were periodically repeated as necessary. Pre-fixed NIV protocol and end point definitions were followed. Descriptive statistics done using Mean and Standard Deviation (SD). Mann-Whitney U test was done for comparing quantitative data. Chi-square test or Fisher’s-exact test was used to compare categorical data. Results: Most common age group for Respiratory Failure (RF) was 41 to 60 years, (mean 56.5±11.6), with a male predominance (M:F=1.4:1). The most common underlying disease leading to RF and requiring NIV support was Acute Exacerbation of Chronic Obstructive Pulmonary Disorder (COPD) (n=31) in Type 2 and pneumonia (n=11) in Type 1 RF. Hypertension (25%) and diabetes mellitus (20%) were common co-morbidities. Favourable outcome was seen in 68.33% patients an average hospital stay of 15 days. The baseline APACHE-II (Acute Physiology and Chronic Health Evaluation) score (p≤0.0001) and Partial Pressure of Oxygen(PaO2)/ Fraction of Inspired Oxygen (FiO2) at 1st hour of NIV (p=0.0054) have significant predictive value the outcome. Reasons for shifting to IMV were: non-improvement of ABG (37.93%), worsening of dyspnoea (24.14%) and haemodynamic instability (20.7%). Average time gap from initiation of NIV to mechanical ventilation in failure cases was 8.03 hours in Type 2 RF and 5.78 hours in Type 1 RF. Fatality rate in Type 2 RF (23.68%) was much less than in Type 1 RF (45.45%). Conclusion: This study strengthens the fact that efficient utilisation of NIV therapy in properly selected patients of acute RF can lead to reduced need for IMV, thus reducing the cost and complications. Disease severity at admission (APACHE-II score), non-improvement of ABG parameters in 1st and 4th hour of NIV initiation, PaO2/FiO2 ratio, development of haemodynamic instability and deteriorating level of consciousness, all play pivotal roles in the outcome assessment.

Bioinformatics Analysis Identifies Potential Key Genes of Peripheral Blood Mononuclear Cell in Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic progressive fibrotic interstitial pneumonia with progressive worsening of dyspnea and lung function. The etiology of IPF is unknown, and the pathogenesis remains unclear. Our study aimed to investigate the key genes of the peripheral blood mononuclear cell in IPF by bioinformatics analysis. Our study used the online Gene Expression Omnibus (GEO) microarray expression profiling dataset GSE28042 to identify differentially expressed genes (DEGs) between IPF patients and healthy controls. We performed the Gene Ontology (GO) and pathway enrichment analyses of genes for annotation, visualization, and integrated discovery. The STRING database constructed Protein-protein interaction (PPI) network analysis, and hub genes were identified by the CytoHubba plugin. Moreover, we used the receiver operating characteristic (ROC) curve to assess the diagnostic value of the hub genes. In total, 28 upregulated and 44 downregulated genes were identified in the differential expression analysis. The protein-protein interaction network (PPI) was established with 69 nodes and 68 edges. The top 10 hub genes were JUN, FOS, STAT3, SOCS3, JUNB, DUSP1, IL4, FCER1A, MS4A2, and CPA3. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways enriched for the important module containing hub genes contained Fc epsilon RI signaling pathway, TNF signaling pathway, Jak-STAT signaling pathway, and MAPK signaling pathway. Additionally, the identified hub genes show high functional similarity and diagnostic value in IPF. Our study used bioinformatics analysis to provide new insight into the mechanisms underlying IPF. However, more experiments are needed to explore the relationships between the top 10 hub genes and IPF in the future.