Priporočila za obravnavo bolnikov s pljučnim rakom

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Biomarkers in routine diagnosis of pleural effusions

Background: Pleural fluid biochemical analysis is the first step in pleural effusion (PE) diagnostics. Our purpose was to analyse the utility of the biomarkers used at our clinic in the routine diagnosis of PE. Methods: We retrospectively reviewed the PE levels of proteins, lactate dehydrogenase (LDH), alpha amylase (AA), pH and glucose in 433 patients who were treated at the University Clinic Golnik in a one-year period and compared these values with the final identified aetiology of the effusions. Results: The majority of the effusions were determined to be a consequence of malignancy (n = 154) or infection (n = 108). In 94 cases the aetiology of the effusions was heart failure and in 54 cases other diseases, while 23 effusions remained aetiologically undetermined. Considering Light’s criteria, the vast majority of the effusions were correctly classified as exudates or transudates (97.1 %). Comparing paramalignant and malignant effusions, we detected significantly lower values of pleural fluid LDH (p < 0.0005) and proteins (p < 0.0005), and higher pH (p < 0.0005) values in the paramalignant effusions. Conclusion: We have found that pleural LDH and proteins are the most helpful biochemical parameters in our routine diagnosis of pleural effusions and helped us to correctly narrow the aetiological spectrum. Furthermore, significantly higher pleural LDH and protein values and a pH below 7.32 additionally facilitated distinguishing between malignant and paramalignant effusions. Parameters such as glucose and AA are useful in selected cases and have a limited role in routine diagnostics

Measurement of pleural pressure during therapeutic thoracentesis (pleural manometry) as a safe and objective method in the assessment of pleural effusion effect on symptom expression

Izhodišča: Bolniki s plevralnim izlivom pogosto potrebujejo razbremenilno plevralno punkcijo (RPP), po kateri navajajo bolj ali manj izrazito olajšanje dispneje. Zaradi varnosti se priporoča, da se med RPP odstrani do 1.500 mL tekočine. Metode: V raziskavo smo vključili 96 bolnikov, pri katerih je bila potrebna RPP. Zbirali smo ocene stopnje dispneje na lestvici VAS pred, takoj po in 2 uri po RPP, pri 73 bolnikih pa še 24 ur po RPP ter beležili količino odstranjene tekočine. Med RPP smo z vodnim manometrom merili plevralne tlake, iz katerih smo izračunali elastanco plevralnega prostora in na podlagi meritev bolnike razdelili v skupine z različnimi elastančnimi krivuljami. Rezultati: Med začetnim plevralnim tlakom in količino odstranjene tekočine ter olajšanjem dispneje po opravljeni RPP smo ugotovili statistično značilno povezanost. Pri največjem deležu bolnikov smo RPP zaključili zaradi pojava simptomov, zaradi meritev plevralnega tlaka pa smo RPP prekinili pri 16 bolnikih (16,7 %). V skupino z normalno elastančno krivuljo smo uvrstili 74 bolnikov, nezmožnost razpenjanja pljuč pa smo ugotovili pri 22 bolnikih. Med RPP ni bilo pomembnih zapletov, kljub temu da smo več kot 1.500 mL izliva odstranili pri 32 (33 %) bolnikih. Zaključek: Višji začetni plevralni tlak je šibko povezan z višjo začetno stopnjo dispneje in večjim olajšanjem dispneje po opravljeni RPP. Najbolj uporabna je dinamika sprememb plevralnega tlaka, s katero lahko že med RPP prepoznamo nezmožnost razpenjanja pljuč. Med RPP s plevralno manometrijo lahko varno odstranimo tudi več kot 1.500 mL tekočineBackground: Patients with pleural effusion often require therapeutic thoracentesis (TT), which results in more or less pronounced dyspnea relief. Due to safety concerns, it is recommended to remove up to a maximum of 1500 mL effusion in one session. Methods: 96 patients in whom TT was indicated were included in the study. VAS dyspnea score before, immediately after, two hours after TT, and in 73 patients additionally 24 hours after TT was collected. The amount of fluid removed was measured. During TT, water manometer was used to measure pleural pressures, from which pleural space elastance was calculated. Based on their elastance curves characteristics, the patients were divided into different groups. Results: We found a correlation between initial pleural pressure/volume of effusion removed and dyspnea relief after TT. TT was most often terminated due to the onset of symptoms, in 16 patients it was terminated due to pleural pressure measurement. 74 patients were classified in the group with a normal elastane curve, in 22 patients we detected unexpandable lungs. Although more than 1500 mL of effusion was removed in 32 (33%) patients, there were no important complications during TT. Conclusion: Higher initial pleural pressure is weakly correlated with higher initial dyspnea and greater dyspnea relief after TT. The dynamic of pleural pressure change is useful for detecting unexpandable lungs during TT. During TT with pleural manometry, more than 1500 mL of pleural fluid can be safely removed

Patch testing with the European baseline series and 10 added allergens : single centre study of 748 patients

Background. The European baseline series (EBS) of contact allergens is subject to change. An allergen is considered for inclusion when routine patch testing of patients with suspected contact dermatitis results in ≥ 0.5% prevalence rate. Objectives. We aimed to determine the frequency of sensitizations to 30 EBS allergens and 10 locally added allergens. Additionally, we assessed the strength and evolution of reactions to all tested allergens and co-reactivity of additional allergens. Methods. Patch testing with our baseline series of 40 allergens was done in 748 consecutive adults. Tests were applied to the upper back and removed by patients after 48 hours. Readings were done on day 3 (D3) and D6 or D7 (D6/7). Positive reactions fulfilled the criteria of at least one plus (+) reaction. Retrospective analysis was done. Results. Eight allergens not listed in the EBS had ≥ 0.5% prevalence rate (i.e., cocamidopropyl betaine, thiomersal, disperse blue mix 106/124, 2-bromo-2-nitropropane-1,3-diol, diazolidinyl urea, propylene glycol, Compositae mix II, and dexamethasone-21-phosphate), and 16.6% of positive reactions would have been missed without D6/7 readings. Conclusion. We propose further studies to evaluate whether cocamidopropyl betaine, disperse blue mix 106/124, 2-bromo-2-nitropropane-1,3-diol, diazolidinyl urea, and Compositae mix II need to be added to the EBS

Immunophenotypes of anti-SARS-CoV-2 responses associated with fatal COVID-19

Background The relationship between anti-SARS-CoV-2 humoral immune response, pathogenic inflammation, lymphocytes and fatal COVID-19 is poorly understood. Methods A longitudinal prospective cohort of hospitalised patients with COVID-19 (n=254) was followed up to 35 days after admission (median, 8 days). We measured early anti-SARS-CoV-2 S1 antibody IgG levels and dynamic (698 samples) of quantitative circulating T-, B- and natural killer lymphocyte subsets and serum interleukin-6 (IL-6) response. We used machine learning to identify patterns of the immune response and related these patterns to the primary outcome of 28-day mortality in analyses adjusted for clinical severity factors. Results Overall, 45 (18%) patients died within 28 days after hospitalisation. We identified six clusters representing discrete anti-SARS-CoV-2 immunophenotypes. Clusters differed considerably in COVID-19 survival. Two clusters, the anti-S1-IgGlowestTlowestBlowestNKmodIL-6mod, and the anti-S1-IgGhighTlowBmodNKmodIL-6highest had a high risk of fatal COVID-19 (HR 3.36–21.69; 95% CI 1.51–163.61 and HR 8.39–10.79; 95% CI 1.20–82.67; p≤0.03, respectively). The anti-S1-IgGhighestTlowestBmodNKmodIL-6mod and anti-S1-IgGlowThighestBhighestNKhighestIL-6low cluster were associated with moderate risk of mortality. In contrast, two clusters the anti-S1-IgGhighThighBmodNKmodIL-6low and anti-S1-IgGhighestThighestBhighNKhighIL-6lowest clusters were characterised by a very low risk of mortality. Conclusions By employing unsupervised machine learning we identified multiple anti-SARS-CoV-2 immune response clusters and observed major differences in COVID-19 mortality between these clusters. Two discrete immune pathways may lead to fatal COVID-19. One is driven by impaired or delayed antiviral humoral immunity, independently of hyper-inflammation, and the other may arise through excessive IL-6-mediated host inflammation response, independently of the protective humoral response. Those observations could be explored further for application in clinical practice

Priporočila za obravnavo bolnikov s pljučnim rakom

In 2019, the Recommendations for the management of patients with lung cancer were published bringing much-needed standardisation of diagnosis and treatment to improve survival of patients with lung cancer. Three years after the original Recommendations were published, the update of the Recommendations brings the most innovations in the chapter on systemic treatment of patients with lung cancer. This reflects the remarkable progress made in the field of understanding the oncogenesis and biology of lung cancer and thus the development of new drugs. The burden of lung cancer remains high, as lung cancer is still the most common cause of cancer related death in our country and worldwide. Lung cancer is responsible for one of five cancer-related deaths. Almost one third of patients with lung cancer do not receive any oncological treatment, either because of poor performance status, comorbidities or the extent of the disease. Half of the patients have metastatic disease at diagnosis, resulting in only small improvements in survival despite advances in the treatment of lung cancer patients. These data remind us that if we are to make major shifts in the management of lung cancer patients, we will need to take different approaches. The most promising seems to be the detection of early stages of lung cancer which offers the best treatment results. The Recommendations written here are guidelines for the management of patients with lung cancer. Only with comprehensive multidisciplinary treatment approach, the best outcome from the prognostically unfavourable disease can be offered.Leta 2019 so bila objavljena Priporočila za obravnavo bolnikov s pljučnim rakom, ki so v slovenski prostor vnesla prepotrebno poenotenje diagnostike in zdravljenja z namenom izboljšanja preživetja bolnikov s pljučnim rakom. Posodobitev Priporočil tri leta po izidu izvirnika prinaša največ novosti v poglavju o sistemskem zdravljenju bolnikov s pljučnim rakom. To kaže na izjemen napredek na področju razumevanja onkogeneze in biologije pljučnega raka ter s tem razvoja novih zdravil. Breme pljučnega raka ostaja veliko, saj je pljučni rak pri nas in v svetu še vedno najpogostejši vzrok smrti zaradi raka. Za vsako peto smrt zaradi raka je odgovoren pljučni rak. Skoraj tretjina bolnikov s pljučnim rakom ne prejme specifičnega onkološkega zdravljenja, bodisi zaradi slabega stanja zmogljivosti, spremljajočih bolezni ali obsega bolezni. Polovica bolnikov ima ob diagnozi razsejano bolezen, zaradi česar izboljšanje preživetja z malimi koraki sledi napredku v zdravljenju bolnikov s pljučnim rakom. Ti podatki nas opominjajo, da se bomo morali za velike premike v obravnavi bolnikov s pljučnim rakom lotiti drugačnih pristopov. Kot najbolj obetavno se ponuja zgodnje odkrivanje bolezni, ko so možnosti ozdravitve pljučnega raka najboljše. Zapisana Priporočila so usmeritev za obravnavo bolnikov s pljučnim rakom. Le s sodobnim multidisciplinarnim pristopom obravnave lahko bolniku ponudimo zdravljenje, ki mu omogoča najboljši izhod prognostično neugodne bolezni

Recommendations for diagnosis and treatment of patients with lung cancer

In 2019, the Recommendations for the management of patients with lung cancer were published bringing much-needed standardisation of diagnosis and treatment to improve survival of patients with lung cancer. Three years after the original Recommendations were published, the update of the Recommendations brings the most innovations in the chapter on systemic treatment of patients with lung cancer. This reflects the remarkable progress made in the field of understanding the oncogenesis and biology of lung cancer and thus the development of new drugs. The burden of lung cancer remains high, as lung cancer is still the most common cause of cancer related death in our country and worldwide. Lung cancer is responsible for one of five cancer-related deaths. Almost one third of patients with lung cancer do not receive any oncological treatment, either because of poor performance status, comorbidities or the extent of the disease. Half of the patients have metastatic disease at diagnosis, resulting in only small improvements in survival despite advances in the treatment of lung cancer patients. These data remind us that if we are to make major shifts in the management of lung cancer patients, we will need to take different approaches. The most promising seems to be the detection of early stages of lung cancer which offers the best treatment results. The Recommendations written here are guidelines for the management of patients with lung cancer. Only with comprehensive multidisciplinary treatment approach, the best outcome from the prognostically unfavourable disease can be offered