Masivna plućna embolija nakon trombocitopenije izazvane heparinom

Immunomediated heparin-induced thrombocytopenia still presents a serious problem, especially when accompanied by thromboembolic complications. We report on a rare case of massive pulmonary embolism following perioperative prophylaxis with unfractionated and low-molecular-weight heparin. The lack of efficacious and safe heparin substitution only allowed for immediate heparin discontinuation and application of adjuvant therapy. A few days after heparin cessation the platelet count tended to return to normal, leading to the patient\u27s full recovery and discharge from the hospital. Heparin therapy requires careful examination of previous history of heparin use as well as close platelet monitoring for up to three weeks of therapy cessation.Imuna trombocitopenija izazvana heparinom još uvijek predstavlja ozbiljan problem, osobito ako je praćena tromboemboličnim komplikacijama. Ovdje prikazujemo rijedak slučaj masivne plućne embolije nastale nakon profilaktične primjene nefrakcioniranog i niskomolekularnog heparina. Manjak učinkovitog i sigurnog nadomjeska za heparin ostavio je samo mogućnost neposrednog ukidanja heparina i uvođenja pomoćne terapije. Nekoliko dana nakon prestanka liječenja heparinom broj trombocita počeo se je normalizirati, a nakon toga bolesnica se je potpuno oporavila i bila otpuštena iz bolnice. Liječenje heparinom zahtijeva brižno prikupljanje anamnestičnih podataka o ranijoj primjeni ovoga pripravka te pažljivo praćenje broja trombocita i do tri tjedna nakon prekida heparinske terapije

The Epidemiology and Diagnostic Approach to Acute Pulmonary Embolism in the University Hospital

The aim of this retrospective study was to evaluate the demographics and clinical characteristics of patients with pulmonary embolism treated in medical intensive care unit (ICU) at the University Hospital during a six-year period, and to assess the impact of several risk factors on patients’ survival. The study included 165 patients, mean age 69.3 ± 13.7 years, predominantly female (70.3%). Dominant symptom was dyspnea (97.0%), the most common sign tachypnea (69.6%). Pulmonary embolism was confirmed by high-probability ventilation/perfusion lung scan or multidetector computed tomography in 71.5% and was regarded as massive in 63 (38.2%), submassive in 23 (13.9%) and non massive in 79 patients (47.9%). Mean hospital stay was 5.7 ± 4.4 days for ICU, and 14.8 ± 9.1 days, overall. The ICU mortality was 26.7% and in-hospital mortality 30.9%. No statistical difference in mortality between male and female patients was observed (30.6% and 31.0%, respectively; p=0.965), but prolonged immobilization (p=0.002), recent operation (p=0.034) or malignancy (p=0.009) were shown to influence the outcome. Although a number of risk factors for developing pulmonary embolism have been identified and heparin prophylaxis along with early mobilization proposed to reduce the incidence, pulmonary embolism remains an important clinical problem with high mortality rate. The diagnostics should not wait and the therapy should start as soon as possible

Survival Analysis of 314 Episodes of Sepsis in Medical Intensive Care Unit in University Hospital: Impact of Intensive Care Unit Performance and Antimicrobial Therapy

Aim: To evaluate epidemiology of sepsis in medical intensive care unit (ICU) in University Hospital, and the impact of ICU performance and appropriate empirical antibiotic therapy on survival of septic patients. Methods: Observational, partly prospective study conducted over 6 years assessed all patients meeting the criteria for sepsis at ICU admission. Clinical presentation of sepsis was defined according to 2001 International Sepsis Definitions Conference. Demographic data, admission category, source of infection, severity of sepsis, ICU or hospital stay and outcome, ICU performance, and appropriateness of empirical antibiotic therapy were analyzed. Results: The analysis included 314 of 5022 (6.3%) patients admitted to ICU during the study period. There were 176 (56.1%) ICU survivors. At the ICU admission, sepsis was present in 100 (31.8%), severe sepsis in 89 (28.6%), and septic shock in 125 (39.8%) patients with mortality rates 17%, 33.7%, 72.1%, respectively. During ICU treatment, 244 (77.7%) patients developed at least one organ dysfunction syndrome. Of 138 (43.9%) patients who met the criteria for septic shock, 107 (75.4) were non-survivors (P<0.001). Factors associated with in-ICU mortality were acquisition of sepsis at another department (odds ratio [OR] 0.06; 95% confidence interval [CI], 0.02-0.19), winter season (OR 0.42; 0.20-0.89), limited mobility (OR 0.28; 0.14-0.59), ICU length of stay (OR 0.82; 0.75-0.91), sepsis-related organ failure assessment (SOFA) score on day 1 (OR 0.80; 0.72-0.89), history of global heart failure (OR 0.33; 0.16-0.67), chronic obstructive pulmonary disease-connected respiratory failure (OR 0.50; 0.27-0.93), septic shock present during ICU treatment (OR 0.03; 0.01-0.10), and negative blood culture at admission (OR 2.60; 0.81-6.23). Microbiological documentation of sepsis was obtained in 235 (74.8%) patients. Urinary tract infections were present in 168 (53.5%) patients, followed by skin or soft tissue infections in 58 (18.5%) and lower respiratory tract infections in 44 (14.0%) patients. Lower respiratory tract as focus of sepsis was connected with worse outcome (P<0.001). Empirical antibiotic treatment was considered adequate in 107 (60.8%) survivors and 42 (30.4%) non-survivors. Patients treated with adequate empirical antibiotic therapy had significantly higher survival time in hospital (log-rank, P=0.001). Conclusion: The mortality rate of sepsis was unacceptably high. The odds for poor outcome increased with acquisition of sepsis at another department, winter season, limited mobility, higher SOFA score on day 1, history of chronic global heart failure, COPD-connected respiratory failure, and septic shock present during ICU treatment, whereas longer ICU length of stay, positive blood culture, and adequate empirical antibiotic therapy were protective factors

Masivna plućna embolija nakon trombocitopenije izazvane heparinom

Immunomediated heparin-induced thrombocytopenia still presents a serious problem, especially when accompanied by thromboembolic complications. We report on a rare case of massive pulmonary embolism following perioperative prophylaxis with unfractionated and low-molecular-weight heparin. The lack of efficacious and safe heparin substitution only allowed for immediate heparin discontinuation and application of adjuvant therapy. A few days after heparin cessation the platelet count tended to return to normal, leading to the patient\u27s full recovery and discharge from the hospital. Heparin therapy requires careful examination of previous history of heparin use as well as close platelet monitoring for up to three weeks of therapy cessation.Imuna trombocitopenija izazvana heparinom još uvijek predstavlja ozbiljan problem, osobito ako je praćena tromboemboličnim komplikacijama. Ovdje prikazujemo rijedak slučaj masivne plućne embolije nastale nakon profilaktične primjene nefrakcioniranog i niskomolekularnog heparina. Manjak učinkovitog i sigurnog nadomjeska za heparin ostavio je samo mogućnost neposrednog ukidanja heparina i uvođenja pomoćne terapije. Nekoliko dana nakon prestanka liječenja heparinom broj trombocita počeo se je normalizirati, a nakon toga bolesnica se je potpuno oporavila i bila otpuštena iz bolnice. Liječenje heparinom zahtijeva brižno prikupljanje anamnestičnih podataka o ranijoj primjeni ovoga pripravka te pažljivo praćenje broja trombocita i do tri tjedna nakon prekida heparinske terapije

Guillain-Barréov sindrom u bolesnika s akutnim infarktom miokarda

We report on a patient with acute neurologic disorder, i.e. Guillain-Barré syndrome, successfully treated by plasmapheresis. The patient suffered a myocardial infarction, which has neither been defined nor described in the available literature as a causative event for acute polyradiculoneuropathy, but merely a random observation. The course of the disease in the patient was complicated by pulmonary infection which we presumed to be a precipitating factor for the occurrence of Guillain-Barré syndrome.Prikazan je bolesnik s akutno nastalim neurološkim poremećajem, Guillain-Barréovim sindromom, koji je uspješno liječen postupkom plazmafereze. Bolesnik je hospitaliziran zbog subakutne slike srčanog infarkta koji prema našim saznanjima i na temelju dostupne literature nije definiran kao uzrok nastanka ove akutne poliradikuloneuropatije, već je opisan kao slučajnost. U našega je bolesnika klinička slika bila komplicirana respiracijskim infektom. Smatramo da je to bio čimbenik koji je ubrzao nastanak Guillain-Barréova sindroma

Spatial Organization and Molecular Correlation of Tumor-Infiltrating Lymphocytes Using Deep Learning on Pathology Images

Beyond sample curation and basic pathologic characterization, the digitized H&E-stained images of TCGA samples remain underutilized. To highlight this resource, we present mappings of tumorinfiltrating lymphocytes (TILs) based on H&E images from 13 TCGA tumor types. These TIL maps are derived through computational staining using a convolutional neural network trained to classify patches of images. Affinity propagation revealed local spatial structure in TIL patterns and correlation with overall survival. TIL map structural patterns were grouped using standard histopathological parameters. These patterns are enriched in particular T cell subpopulations derived from molecular measures. TIL densities and spatial structure were differentially enriched among tumor types, immune subtypes, and tumor molecular subtypes, implying that spatial infiltrate state could reflect particular tumor cell aberration states. Obtaining spatial lymphocytic patterns linked to the rich genomic characterization of TCGA samples demonstrates one use for the TCGA image archives with insights into the tumor-immune microenvironment

Large expert-curated database for benchmarking document similarity detection in biomedical literature search

Document recommendation systems for locating relevant literature have mostly relied on methods developed a decade ago. This is largely due to the lack of a large offline gold-standard benchmark of relevant documents that cover a variety of research fields such that newly developed literature search techniques can be compared, improved and translated into practice. To overcome this bottleneck, we have established the RElevant LIterature SearcH consortium consisting of more than 1500 scientists from 84 countries, who have collectively annotated the relevance of over 180 000 PubMed-listed articles with regard to their respective seed (input) article/s. The majority of annotations were contributed by highly experienced, original authors of the seed articles. The collected data cover 76% of all unique PubMed Medical Subject Headings descriptors. No systematic biases were observed across different experience levels, research fields or time spent on annotations. More importantly, annotations of the same document pairs contributed by different scientists were highly concordant. We further show that the three representative baseline methods used to generate recommended articles for evaluation (Okapi Best Matching 25, Term Frequency-Inverse Document Frequency and PubMed Related Articles) had similar overall performances. Additionally, we found that these methods each tend to produce distinct collections of recommended articles, suggesting that a hybrid method may be required to completely capture all relevant articles. The established database server located at https://relishdb.ict.griffith.edu.au is freely available for the downloading of annotation data and the blind testing of new methods. We expect that this benchmark will be useful for stimulating the development of new powerful techniques for title and title/abstract-based search engines for relevant articles in biomedical research.Peer reviewe

The epidemiology and diagnostic approach to acute pulmonary embolism in the university hospital [Epidemiološki pokazatelji i dijagnostički pristup bolesniku s akutnom plućnom embolijom u kliničkoj bolnici]

The aim of this retrospective study was to evaluate the demographics and clinical characteristics of patients with pulmonary embolism treated in medical intensive care unit (ICU) at the University Hospital during a six-year period, and to assess the impact of several risk factors on patients' survival. The study included 165 patients, mean age 69.3 +/- 13.7 years, predominantly female (70.3%). Dominant symptom was dyspnea (97.0%), the most common sign tachypnea (69.6%). Pulmonary embolism was confirmed by high-probability ventilation/perfusion lung scan or multidetector computed tomography in 71.5% and was regarded as massive in 63 (38.2%), submassive in 23 (13.9%) and non massive in 79 patients (47.9%). Mean hospital stay was 5.7 +/- 4.4 days for ICU, and 14.8 +/- 9.1 days, overall. The ICU mortality was 26.7% and in-hospital mortality 30.9%. No statistical difference in mortality between male and female patients was observed (30.6% and 31.0%, respectively; p = 0.965), but prolonged immobilization (p = 0.002), recent operation (p = 0.034) or malignancy (p = 0.009) were shown to influence the outcome. Although a number of risk factors for developing pulmonary embolism have been identified and heparin prophylaxis along with early mobilization proposed to reduce the incidence, pulmonary embolism remains an important clinical problem with high mortality rate. The diagnostics should not wait and the therapy should start as soon as possible

Timing of troponin T measurements in triage of pulmonary embolism patients

AIM: To determine the appropriate timing of cardiac troponin T (cTnT) measurement for the early triage of pulmonary embolism (PE) patients. ----- METHODS: In this single-center prospective study, PE was confirmed in all patients using computed tomography. 104 consecutive patients were divided into three groups (high-risk, intermediate, and low-risk) based on their hemodynamic status and echocardiographic signs of right ventricular dysfunction. cTnT levels were measured on admission and then after 6, 24, 48, and 72 hours with threshold values greater than 0.1 ng/mL. ----- RESULTS: Intermediate-risk PE patients had higher cTnT levels than low-risk patients already in the first measurement (P=0.037). Elevated cTnT levels significantly correlated with disease severity after 6 hours (intermediate vs low risk patients, P=0.016, all three groups, P=0.009). ----- CONCLUSION: In hemodynamically stable patients, increased cTnT level on admission differentiated intermediate from low-risk patients and could be used as an important element for the appropriate triage of patients

Efficacy and Safety of Propofol Sedation During Urgent Upper Gastrointestinal Endoscopy – A Prospective Study

The aim of this study was to investigate both the efficacy and safety of sedation with propofol during urgent therapeutic gastroscopy in patients with upper gastrointestinal bleeding. This prospective study included a total of 110 patients. Propofol was administered intravenously at the starting dose of 1 mg/kg body weight and was followed by repeated doses. Oxygen saturation and heart rate were monitored by pulse oxymetry. The mean dose of propofol administered was 161 49 mg. Urgent upper GI endoscopy under propofol sedation was successful in 98% of cases. Endoscopists rated the sedation as good in 83.6%, satisfactory in 14.5%, and poor in 1.8% of patients. Potentially harmful drop in oxygen saturation below 85% was observed in 5.5% of patients, whereas a temporary drop in heart rate below 50 beats/min was observed in 11.8%, not requiring any intervention. Almost 93% of patients could not remember the beginning or the end of the intervention. This data demonstrates that sedation with propofol is suitable for use in patients with upper gastrointestinal bleeding undergoing urgent endoscopy