INCREMENTO DELLA SOPRAVVIVENZA IN PAZIENTI AFFETTI DA IPERTENSIONE POLMONARE TROMBOEMBOLICA INOPERABILE

Pazienti affetti da ipertensione polmonare tromboembolica inoperabili (Inop-CTEPH) trattati con le terapie convenzionali hanno una scarsa sopravvivenza. Abbiamo comparato la sopravvivenza a tre anni dei pazienti trattati con terapia convenzionale e quelli trattati con terapia convenzionale associati ad una combinazione di nuovi farmaci vasodilatatori polmonari. Abbiamo inoltre valutato il loro decorso clinico. Sono stati valutati, dal 1991 al 2009, 34 pazienti Inop-CTEPH consecutivi tramite cateterismo cardiaco destro (RHC) e scintigrafia polmonare da perfusione (PLS): 7 pazienti sono stati sottoposti a trattamento chirurgico mentre i restanti 27 casi non erano risultati suscettibili all’intervento di tromboendoarterectomia. Di questi 27 pazienti, i 12 valutati dal 1991 al 2003 sono stati trattati con le sole terapie convenzionali (Gruppo 1), mentre i 15 pazienti valutati dal 2004 al 2009 (Gruppo 2) sono stati trattati con terapie convenzionali in combinazione a farmaci di nuova generazione. Nella valutazione emodinamica basale non emergevano differenze significative tra i due gruppi in studio. Basandoci sul decorso clinico dei pazienti, sono stati intrapresi i nuovi farmaci vasodilatatori e la supplementazione di ossigeno nei pazienti del Gruppo 2. Di questi, 7 pazienti con decorso clinico peggiore sono stati sottoposti a rivalutazione emodinamica tramite RHC durante terapia e 4 di essi anche a scintigrafia polmonare da perfusione di controllo. Coloro che non hanno ripetuto il RHC avevano basalmente valori più bassi di pressione arteriosa media in arteria polmonare e di livelli di proormone del peptide natriuretico cerebrale (NT-proBNP), oltre che una maggiore saturazione venosa mista (SvO2) e una migliore tolleranza allo sforzo (p = 0.022, 0.015, 0.044 e 0.003 rispettivamente). Durante terapia, i pazienti che avevano ripetuto il RHC si caratterizzavano per una ridotta resistenza vascolare polmonare (p = 0.012), un incremento del valore di eccesso basi (p = 0.002) e una significativa redistribuzione del flusso ematico polmonare evidenziabile alla scintigrafia polmonare da perfusione. Dopo un follow-up di 3 anni la sopravvivenza del Gruppo 2 era 86% contro il 31% di quella dei pazienti del Gruppo 1 (p = 0.031). Nei pazienti Inop-CTEPH il decorso clinico potrebbe aiutare a scegliere farmaci ed ossigenoterapia al fine di migliorare i parametri emodinamici, lo scambio gassoso respiratorio e la sopravvivenza a lungo termine

Pleural Effusion in COVID-19 Pneumonia: Clinical and Prognostic Implications-An Observational, Retrospective Study

Background: COVID-19 presents with a wide spectrum of clinical and radiological manifestations, including pleural effusion. The prevalence and prognostic impact of pleural effusion are still not entirely clear. Patients and methods: This is a retrospective, single-center study including a population of consecutive patients admitted to the University Hospital of Cisanello (Pisa) from March 2020 to January 2021 with a positive SARS-CoV-2 nasopharyngeal swab and SARS-CoV-2-related pneumonia. The patients were divided into two populations based on the presence (n = 150) or absence (n = 515) of pleural effusion on chest CT scan, excluding patients with pre-existing pleural effusion. We collected laboratory data (hemoglobin, leukocytes, platelets, C-reactive protein, procalcitonin), worst PaO2/FiO(2) ratio as an index of respiratory gas exchange impairment, the extent of interstitial involvement related to SARS-CoV-2 pneumonia and data on intensity of care, length of stay and outcome (discharge or death). Results: The prevalence of pleural effusion was 23%. Patients with pleural effusion showed worse gas exchange (p < 0.001), longer average hospital stay (p < 0.001), need for more health care resources (p < 0.001) and higher mortality (p < 0.001) compared to patients without pleural effusion. By multivariate analysis, pleural effusion was found to be an independent negative prognostic factor compared with other variables such as increased C-reactive protein, greater extent of pneumonia and older age. Pleural effusion was present at the first CT scan in most patients (68%). Conclusions: Pleural effusion associated with SARS-CoV-2 pneumonia is a relatively frequent finding that is confirmed to be a negative prognostic factor. Identifying early prognostic factors in an endemic-prone disease such as COVID-19 is necessary to optimize its clinical management. Further clinical studies aimed at better characterizing pleural effusion in these patients will be appropriate in order to clarify its pathogenetic role

Platelet-Rich Plasma Modulates Gap Junction Functionality and Connexin 43 and 26 Expression During TGF-β1-Induced Fibroblast to Myofibroblast Transition: Clues for Counteracting Fibrosis

Skeletal muscle repair/regeneration may benefit by Platelet-Rich Plasma (PRP) treatment owing to PRP pro-myogenic and anti-fibrotic effects. However, PRP anti-fibrotic action remains controversial. Here, we extended our previous researches on the inhibitory effects of PRP on in vitro transforming growth factor (TGF)-β1-induced differentiation of fibroblasts into myofibroblasts, the effector cells of fibrosis, focusing on gap junction (GJ) intercellular communication. The myofibroblastic phenotype was evaluated by cell shape analysis, confocal fluorescence microscopy and Western blotting analyses of α-smooth muscle actin and type-1 collagen expression, and electrophysiological recordings of resting membrane potential, resistance, and capacitance. PRP negatively regulated myofibroblast differentiation by modifying all the assessed parameters. Notably, myofibroblast pairs showed an increase of voltage-dependent GJ functionality paralleled by connexin (Cx) 43 expression increase. TGF-β1-treated cells, when exposed to a GJ blocker, or silenced for Cx43 expression, failed to differentiate towards myofibroblasts. Although a minority, myofibroblast pairs also showed not-voltage-dependent GJ currents and coherently Cx26 expression. PRP abolished the TGF-β1-induced voltage-dependent GJ current appearance while preventing Cx43 increase and promoting Cx26 expression. This study adds insights into molecular and functional mechanisms regulating fibroblast-myofibroblast transition and supports the anti-fibrotic potential of PRP, demonstrating the ability of this product to hamper myofibroblast generation targeting GJs

Venous thromboembolism secondary to hospitalization for COVID-19: patient management and long-term outcomes

Background: Venous thromboembolism (VTE) is a complication of COVID-19 in hospitalized patients. Little information is available on long-term outcomes of VTE in this population. Objectives: We aimed to compare the characteristics, management strategies, and long-term clinical outcomes between patients with COVID-19-associated VTE and patients with VTE provoked by hospitalization for other acute medical illnesses. Methods: This is an observational cohort study, with a prospective cohort of 278 patients with COVID-19-associated VTE enrolled between 2020 and 2021 and a comparison cohort of 300 patients without COVID-19 enrolled in the ongoing START2-Register between 2018 and 2020. Exclusion criteria included age <18 years, other indications to anticoagulant treatment, active cancer, recent (<3 months) major surgery, trauma, pregnancy, and participation in interventional studies. All patients were followed up for a minimum of 12 months after treatment discontinuation. Primary end point was the occurrence of venous and arterial thrombotic events. Results: Patients with VTE secondary to COVID-19 had more frequent pulmonary embolism without deep vein thrombosis than controls (83.1% vs 46.2%, P <.001), lower prevalence of chronic inflammatory disease (1.4% and 16.3%, P <.001), and history of VTE (5.0% and 19.0%, P <.001). The median duration of anticoagulant treatment (194 and 225 days, P = 0.9) and the proportion of patients who discontinued anticoagulation (78.0% and 75.0%, P = 0.4) were similar between the 2 groups. Thrombotic event rates after discontinuation were 1.5 and 2.6 per 100 patient-years, respectively (P = 0.4). Conclusion: The risk of recurrent thrombotic events in patients with COVID-19-associated VTE is low and similar to the risk observed in patients with VTE secondary to hospitalization for other medical diseases

Risk stratification in patients with acute pulmonary embolism: the role of arterial blood gas exchange

Introduction - Currently, acute pulmonary embolism (PE) remains one of the leading causes of morbidity and mortality in the cardiovascular setting. PE is a great health problem and may present as a cardiovascular emergency. PE management and treatment are customized by mortality risk. Indeed, the European Society of Cardiology/European Respiratory Society (ESC/ERS) 2014 guidelines (GL) divide PE patients, initially, based on the presence of clinical parameters, such as systemic arterial hypotension or cardiogenic shock, subsequently, using first prognostic compositum score (pulmonary embolism severity index (PESI)), then right ventricular (RV) dysfunction signs, detected by an imaging test and cardiac laboratory biomarkers1. PESI is the most extensively validated prognostic score1, 2–5; however, owing to the complexity of the original PESI, that includes eleven variables, a simplified version known as simplified PESI (sPESI) has been developed and validated6,7. According to current GL1 on the diagnosis and management of PE, prognostic assessment is required, concurrently with diagnosis, to define risk stratification and therapeutic decision-making. Proposed risk stratification, using these tools, divides PE patients in high, intermediate-high, intermediate-low and low early mortality risk, considering early death risk as PE correlated in-hospital or 30-day mortality rate GL1. Clinical symptoms and signs of acute RV failure, such as persistent arterial hypotension and cardiogenic shock, indicate a high risk of early death and those patients need a thrombolytic therapy1, if it is not contraindicated. Subsequently, the acute RV dysfunction findings, demonstrated by an imaging exams, are determinant factors of outcome in acute PE, as well as RV dysfunction or myocardial injury biomarkers1. Many studies have shown RV dysfunction, as assessed by trans-thoracic echocardiography (TTE), as one of the strongest predictors of early mortality in PE patients8-10: TTE demonstrates RV dilatation, akinesia/hypokinesia or pressure overload. However, the test is operator-dependent and not necessarily available around the clock in all institutions, moreover, TTE criteria of RV dysfunction are not definitely an universally standardized1. Tomographic pulmonary angiography (CTPA) is currently considered the diagnostic gold standard for PE1. In addition to its diagnostic role, the test has also the ability to highlight RV dilation and other radiological signs with prognostic significance1,11-13. Finally, brain natriuretic peptide (BNP) or N-terminal pro-brain natriuretic peptide (NT-proBNP) increased release reflects a RV pressure overload indirected sign and the severity of haemodynamic impairment after an acute PE. Their rise correlate with worse prognosis, such as elevated plasma troponin concentrations that is associated with high mortality both in unselected patients and in haemodynamically stable patients1,14–17. Nowadays, arterial blood gas analysis (BGA) remains a first-level test in patients with suspected PE for the evaluation of acide-base status and gas exchange. BGA is usually used to describe the clinical presentation of patients with suspected PE or to explain pathophysiological mechanisms, but it does not play a major role as prognostic factor1. Only arterial hypoxaemia and low arterial oxygen saturation are contained in some prognostic score such as the Geneva and PESI ones, in association with many other markers1,5,18. In one study, hypoxemia was found to be an independent predictor of three-month all causes mortality in PE patients19. Currently, despite importance advances in diagnosis and treatment, assessment of risk and appropriate management of patients with PE remains a difficult task in clinical practice. This is particularly true in haemodynamically stable intermediate risk patients who, in clinical practice, are the most of the cases. Besides, there is an increasing interest in risk stratification using standardized blood tests, that do not require advanced skills and can be easily standardized. Aim - Primary end-point of the study is to investigate whether a new parameter based on arterial blood gas exchange may predict in-hospital clinical deterioration. Clinical deterioration is defined as rescue thrombolysis, need for positive inotropic support, ventilation support or endotracheal intubation, cardiopulmonary resuscitation or need of recovery in intensive care units. This, in fact, might help risk stratification, mostly in the intermediate class of risk proposed by current GL. Secondary end-points consists in evaluating the arterial blood gas exchange data to predict in-hospital and one-month all-cause mortality. Materials and methods. - In our study we evaluate consecutive patients with a CTPA confirmed diagnosis of pulmonary embolism, hospitalized in a tertiary and a secondary care units (Cisanello Hospital, Pisa and Lotti Hospital, Pontedera), coming from the emergency department, from April 2013 to August 2015. Patients were eligible if their PE were objectively confirmed according to current GL by the presence of filling defects within the pulmonary arterial bed on CTPA study1. In every patient the clinical assessment of the haemodynamic status was performed. Moreover sPESI, RV dysfunction signs detected by TTE, cardiac laboratory biomarkers (BNP and/or NT-proBNP, high-sensibility troponin (TrHS) were determined. Besides, we collected the values of room air or oxygen support arterial BGA parameters, performed in the first hour after emergency room admission and before performing the CTPA study. We followed our patients in their in-hospital iter, while, after demission, the patients have been followed by their family physicians for at least one month; in case of death all relevant data have been obtained from family physicians or hospital files or civil registry. Results - A total of 371 PE patients were included during the study. We divided population study in 4 prognostic classes, according to GL. The normality of all prognostic markers was observed in only the 6.2% of study population (low-risk class), the most part of patients (89.8%) belonged to the intermediate risk class, mostly to the low-intermediate one, only 4.0% were hemodynamically instable (high-risk class). All study patients had a complete echocardiographic examination and more over the 50% of the cases showed at least a RV dysfunction sign. Overall, 319 patients (86%) presented a sPESI score ≥ 1. About biomarker alteration, Tr HS was elevated ( ≥ 60 pg * mL-1) in 184 patients (49.6%), and BNP ( ≥ 75 pg * mL-1) in 185 (49.9%). NT – proBNP (≥ 600 pg * mL-1) was measured only in 252 patients and it resulted altered in the 44.8% of the cases. About BGA, we measured all parameters, but we chose PaO2 st./FiO2 and PaO2 /FiO2 as possible prognostic markers, because of their simplicity and immediacy of calculation. We fixed a cut-off value of 300 mmHg, because a relative cut-off in PE patients is not available in the literature. This threshold, generally used to define acute lung injury (ALI), indicates a condition of severe respiratory failure. In overall population, PaO2/FiO2 was altered in 43% of the cases, while PaO2st./FiO2 is low in 220 patients (59.3%). PaO2/FiO2 and PaO2 st./FiO2 were significantly associated with all other considered clinical or blood markers or RVD detected by TTE. During the follow-up (one month), 34 patients died (9.2%), of these 23 (6.2% of study population, 67.7% total death), during hospital stay. Clinical deterioration presented in 84 patients (22.6%), within hospital stay. Univariate cox regression analysis showed a significantly elevated risk (HR = 4.3; p < 0.001) in patients with altered troponin values considering the compositum score, but this was also true correlating PaO2 st./FiO2 (HR = 3.3; p = 0.007). Moreover, the risk based on BNP and NT pro-BNP (respectively HR = 3.9 , p = 0.001 and HR = 3.7, p = 0.001) is high. Concerning echocardiogram signs, the contemporary of RV free wall akinesia or hypokinesia, RV enlargement and pulmonary hypertension findings increased more than 3 times the risk of in-hospital mortality (HR = 3.4, p < 0.001). sPESI class also elevated risk (HR = 1.5, p < 0.001). However, in multivariate logistic regression analisys, including the described variables and age quartiles, no parameters, including troponin and other biomarkers, was resulted independently significant in our population, considering the compositum score. Univariate cox regression analysis showed similar results considering in-hospital or one-month mortality, while in multivariate logistic regression showed only sPESI was independent predictor of in-hospital mortality (HR = 2.1, p = 0.002). A significant difference in pH values only between high-risk and not high risk populations was observable. Besides, high-risk prognostic class was characterized by a significant increased fraction of inspired oxygen and a greater arterial lactate values, compared to other prognostic classes. PaO2/FiO2 and PaO2 standard/FiO2 values demonstrated a decreasing trend, considering increased risk of adverse events. Elaborating Kaplan – Meier curve by PaO2/FiO2 and PaO2 standard/FiO2 values, altered BGA values correlated with worse prognosis patients. Besides, considering only intermediate-risk patients, analysis showed that PaO2/FiO2 and PaO2 standard/FiO2 alteration were significantly different in better and worse prognosis patients (p < 0,05), both in low-intermediate and in high-intermediate risk classes. Finally, calculating positive predictive value (PPV) for primary and secondary end-points, it was similar to that obtained in other studies109, 110, 111 concerning “classical” PE prognostic markers, such as troponin, BNP and NT-pro BNP: PO2/FiO2 PPV is 37.3% for primary end-point and 11.2% and 13% for secondary ones, while PO2 st./FiO2 PPV is 32.3% for compositum score and respectively 10% and 12.7% for in-hospital and one-month mortality. However, it is more interesting negative predictive value (NPV). PO2/FiO2 and PO2 st./FiO2 NPV are 88.6% and 91.4% for compositum score, while for in-hospital mortality they are respectively 97.6% and 99.3%, they are 93.8% and 96% for one-month mortality. It means that if PO2/FiO2 or PO2 st./FiO2 are normal, patients probably will not have a bad clinical course. Discussion - Concurrently, with the diagnosis of PE, prognostic assessment is required in order to stratify patients for risk of early death and, consequently, chose the best available therapeutic decision-making. Prognostic markers actually proposed by GL are the following: hemodynamic stability, prediction rules, cardiac biomarkers and RVD findings detected by an imaging-test1. Hemodynamic instability detects early high-risk mortality patients, who need a specific diagnostic-therapeutic pathway. On the contrary, patients with hemodynamic stability can be divided in early-death-risk classes, evaluating others prognostic markers1. sPESI 1 in low-intermediate and high-intermediate risk classes. This prognostic classification is based on many studies which had the power to correlate each marker to adverse events. The main strength of sPESI lies in the reliable identification of patients at low-risk for one-month mortality and, also in our study, we obtained the same result. Besides, RV dilatation, akinesia/hypokinesia or pressure overload collected by TTE have been identified as independent predictors of an adverse outcome92, even if this type of skill is operator-dependent, not always available any time in any hospital and diagnostic criteria are not always evaluated in a standard way. In the population we studied RVD was significantly more frequent both in patients dying in acute phase or within one month. In particular, all patients dead during in-hospital stay showed RVD signs. In the literature TTE proved a low positive predictive value 94,95, even if TTE would be a very sensible skill. Besides, the increased release of some cardiac biomarkers, such as BNP or NT-proBNP, correlate with worse prognosis15, 97, 110, 111. At the same time, elevated plasma troponin concentrations are associated with high mortality both in unselected patients and in haemodynamically stable patients1,14–17. In the patients we studied we obtained this type of correlation, when considering the compositum score (including clinical deterioration and in-hospital death) and in-hospital or one-month mortality. A meta-analysis, covering a total of 2000 patients, showed elevated cardiac troponin I or T concentrations in about 50% of the patients with acute PE99, however, other reports have suggested a limited prognostic value of elevated troponins in normotensive patients100. The reported positive predictive value of troponin elevation for PE-related early mortality ranges from 12 – 44%, while the negative predictive value is high. As it happens in the case of troponin, BNP and NT-proBNP, the positive predicted value obtained in the case of PaO2/FiO2 and PaO2 st./FiO2 is almost low, while the negative predicted value is high, both for adverse and mortality events. In our study, the univariate analysis reflects all these correlations and highlights same results even in main BGA parameters (PaO2/FiO2 e PaO2 st./FiO2). The distribution of altered PaO2/FiO2 and PaO2 st./FiO2 values in PE patients with adverse or benign outcomes, is similar to the distribution of “classical” prognostic markers, considering primary end-point (clinical deterioration and in-hospital death) and secondary ones (in-hospital and one-month death). However, a multivariate regression analysis, including all the markers and quartiles for patients age, showed that sPESI was the only independent variable which predicts in-hospital mortality risk. This suggests a possible interaction towards classical markers and PaO2/FiO2 and PaO2 st./FiO2 values: Correlating PaO2/FiO2 and PaO2 st./FiO2 values with the commonly utilized markers, we obtained significant statistic concordance. Inside the intermediate class, the PaO2/FiO2 and PaO2 st./FiO2 alterations increase considerably the risk of adverse events and it allows speculate speculate a possible new stratification of the low-intermediate and high-intermediate classes. Moreover gas exchange data show significant differences among the four patients prognostic classes: the high risk class is characterized by increased fraction of inspired oxygen, greater arterial lactate values (Table 17). At the same time PaO2/FiO2 and PaO2 st./FiO2 show a decreasing trend from low to high risk class; these data could reflect a greater gas exchange inefficiency in the high risk class. The new prognostic parameter (PaO2 st./FiO2) that we introduced reflects the efficiency of blood exchanges, it is commonly calculated in clinical practice since it is really simple to measure. Perhaps, it has not employed insofar, since the classically utilized prognostic markers derive from a “cardiologic” culture, that makes use mostly of echocardiogram and biochemical markers originally investigated in the left heart pathologies. However, a good correlation is present between both PaO2/FiO2 and PaO2 st./FiO2 findings, as well as troponin and echocardiography, with clinical deterioration and PE-related deaths. Limits of the study The main limit of this study is that multivariate regression analysis revealed PaO2/FiO2 and PaO2 st./FiO2 were not independent predictor of a worse clinical course, however we also need to consider that this result could be the expression of classical markers and gas exchange data interaction. In fact, cardiac laboratory biomarkers and gas exchange data could be different expressions of the same pathofisiological process. On the other hand, it is possible that the sPESI prognostic strength is so sobvious that the other markers are not statistically significant. Conclusion - The use of the new parameter, PaO2/FiO2 and/or PaO2 st./FiO2 values, may help stratify patients with PE for the risk of early death. Indeed, when this ratio is 300 mmHg seems a sign of better clinical course. Such patients, therefore, could be candidate for a short-term hospitalization or for an outpatient treatment of PE. In the clinical practice, the following flow chart could be used. Once the patients are included in a prognostic GL classe by using sPESI and the other markers, PaO2/FiO2 and PaO2 st./FiO2 values could provide a higher probability of worse or better clinical course. Further data are however necessary to assess whether PaO2/FiO2 and/or PaO2 st./FiO2 values, alone or in combination with clinical, blood or imaging findings of RVD, can be used to manage and treat PE patients

Similar use of intonation structure in early implanted children and hearing children: The case of Italian

International audienceThis work presents an analysis of the intonation competence in a group of Italian children with cochlear implant (CI). Early cochlear implantation plays a crucial role in language development for children who were born deaf in that it favours the acquisition of complex aspects of language, such as the intonation structure. A story-generation task, the Narrative Competence Task, was used to elicit children’s stories. Narrations produced by 8 early implanted children and by 16 children with typically hearing (TH) (8 one-to-one matched considering the chronological age, TH-CA, and 8 considering the hearing age, TH-HA) were analysed considering intonation features (pitch accent distribution, edge tones and inner breaks). Results show that children with CI produce intonation patterns that are similar to those of both TH-CA and TH-HA control groups. Few significant differences were found only between children with CI and children matched for TH-HA in the use of rising edge tones. These results are discussed in light of the role of cognitive development in using prosody and intonation and the importance of early CI implantation. This study shows for the first time that intonation use of early implanted children is not different from that of typically developing children with the same chronological age

Prognostic role of respiratory failure in acute pulmonary embolism: a prospective multicenter study

Acute pulmonary embolism (APE) is a significant cause of mortality. While numerous studies have tried to improve its prognostic evaluation, the risk stratification remains challenging [ [1] ]. In general, the aim of any prognostic tool is to identify patients who require fibrinolysis and distinguish between patients who need close clinical monitoring from patients for whom an early or even immediate discharge would be sufficient. Despite extensive research, however, the risk stratification in PE remains uncertain. Over the last several years, a cardiology-oriented vision has prevailed, supported by several studies showing that abnormal levels of cardiac biomarkers or instrumental right ventricular dysfunction (RVD) predict an increased risk of early adverse events

Role of perfusion defects at follow-up lung scan in predicting recurrences after a first episode of symptomatic pulmonary embolism: a retrospective analysis

The optimal duration of anticoagulant therapy after a first episode of unprovoked pulmonary thromboembolism is not fully defined. The identification of patients more prone to recurrence would be useful in this context but is currently relatively unreliable. Perfusion lung scan (PLS) is an established approach for the follow-up of patients with pulmonary embolism to identify recurrences and to help in the diagnosis of chronic thromboembolic pulmonary hypertension. The aim of the study was to investigate the potential role of residual perfusion defects at follow-up perfusion scans in predicting pulmonary embolism recurrences. We retrospectively analyzed PLSs of 252 patients with a first episode of unprovoked, symptomatic pulmonary embolism. The agreement between two experienced readers, as assessed by the kappa test, was good, with kappa indices ranging from 0.84 (baseline scan) to 0.98 (last prerecurrence available scan). Sixteen patients developed a late (at least 1 month from the index episode) recurrence identified through the appearance of (a) new perfusion defect(s) not matching radiograph alterations. When patients were divided based on the presence or absence of at least two unperfused segments at the 6-month follow-up lung scan, the probability of recurrence was significantly higher in the latter (P = 0.03 by log-rank test). The use of persistent perfusion defects at follow-up PLS as a guide to determine optimal duration of anticoagulant therapy after a first, unprovoked episode of acute pulmonary thromboembolism is a viable strategy that should be further investigated

Identification of a subgroup of non cystic fibrosis (CF) bronchiectasis patients with asthmatic traits

Background: Asthma, bronchiectasis, and COPD are the 3 most prevalent chronic airway diseases. They overlap with a higher frequency than expected. Although the overlapping relationship is not clear, the term "overlap syndrome" is well accepted. Many studies were performed in subjects with severe asthma and bronchiectasis, rarely "non severe" asthma was investigate in bronchiectasis subjects. Aims: To evaluate several tools to express asthma traits in bronchiectasis. Methods: Outpatient subjects with non-CF bronchiectasis, attending for the Pneumology Unit of Pisa, were evaluated. Baseline spirometry, reversibility test with salbutamol and/or methacholine challenge tests were performed. FeNO and/or induce sputum were collected too. Subjects known for primarily severe asthma are excluded. Results: Out of 208 subjects, 51 showed reversibility test and/or methacholine challenge test positive for asthma trait (24,5%). They don't differ from the others patients in terms of age, gender, detection of microbes in airways, but the pulmonary function (FEV1, RV expressed in % of predicted), the percentage of cells on sputum or blood (neutrophils, eosinophils) and FeNO values were different significally. Conclusion: The main tools to detect asthma, reversibility and methacholine challenge tests, are able to identify subjects with concomitant asthma and bronchiectasis. The identified group is significantly characterized with asthma traits, including probable eosinophilic trait. In the point of view of precision medicine, the treatment should be addressed on treatable traits and our results could have some implications to choice the treament in bronchiectasis with concomitant asthma features