Extensive ecchymosis and retroperitoneal hemorrhage due to acquired hemophilia-A following influenza vaccination: A case report

INTRODUCTION

Acquired hemophilia-A (AHA) is a rare but potentially life-threatening impaired coagulation disorder characterized by the development of autoantibodies against clotting factor VIII. Only a few case reports have been experienced with influenza vaccine-triggered AHA. Here, we report a case of severe hemorrhagic disorder due to AHA following influenza vaccine, which was successfully treated.

PATIENT CONCERNS

The patient presented to the emergency department because of several severe, progressively worsening bruises after receiving the influenza vaccination. Consequently, the patient required intubation due to nasal-oral bleeding, which compromised the airway, and retroperitoneal hemorrhage with shock also developed.

DIAGNOSIS

AHA was confirmed through a coagulation factor assay, including coagulation activity and antibody testing, which is possibly triggered by influenza vaccination.

INTERVENTION

Low-dose cyclophosphamide and hydrocortisone were prescribed until activated partial thromboplastin time showed normal levels. Coagulation factor VIIa was administered, and aggressive blood transfusion was carried out concurrently to address the blood loss.

OUTCOMES

The upper airway bleeding subsided and bleeding tendencies had been corrected to normal. The patient was smoothly weaned from the ventilator and recovered from critical illness. She was then discharged on the 19th day.

LESSONS

The activated partial thromboplastin time mixing test can be performed immediately to establish the initial differential diagnosis and treatment plan for severe coagulopathy. AHA may be triggered by vaccination, with the hypothesis of activation of autoantibodies and molecular mimicry; this mechanism should be further studied.

Clinical characteristics and treatment outcomes among the hospitalized elderly patients with COVID-19 during the late pandemic phase in central Taiwan

BACKGROUND

There is a lack of information regarding outcomes of elderly patients hospitalized with COVID-19 following the widespread use of COVID-19 vaccines and antiviral agents.

METHODS

A retrospective study was conducted between January and August 2022, enrolling patients aged 65 years or older. Patients were categorized into two groups: 'old' (65-79 years) and 'oldest-old' (80 years or more). Multivariate regression was employed to identify independent prognostic factors for in-hospital mortality.

RESULTS

A total of 797 patients were enrolled, including 428 old and 369 oldest-old patients. In each subgroup, 66.6 % and 59.6 % of patients received at least one dose of the COVID-19 vaccine, respectively. Approximately 40 % of the patients received oral antiviral agents either before or upon hospital admission. A greater percentage of the oldest-old patients received remdesivir (53.4 % versus 39.7 %, p < 0.001), dexamethasone (49.3 % versus 36.7 %, p < 0.001), and tocilizumab (10.0 % versus 6.8 %, p < 0.001) than old patients. The mortality rate was comparable between the two age subgroups (14 % versus 15.2 %). Independent predictors of in-hospital mortality included disease severity and comorbidities such as end-stage renal disease (ESRD), cirrhosis, solid tumours, and haematologic malignancies. Ageing was not correlated with increased in-hospital mortality across all comorbidity subgroups.

CONCLUSIONS

In the later stages of the pandemic, with widespread vaccination and advancements in COVID-19 treatments, outcomes for hospitalized elderly and oldest-old patients with COVID-19 have improved. The influence of age on in-hospital mortality has diminished, while comorbidities such as ESRD, cirrhosis, solid tumours, and hematologic malignancies have been associated with mortality.

Application of a multiplex molecular pneumonia panel and real-world impact on antimicrobial stewardship among patients with hospital-acquired and ventilator-associated pneumonia in intensive care units

BACKGROUND

The optimal timing for applying the BioFire FilmArray Pneumonia Panel (FAPP) in intensive care unit (ICU) patients with hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP) remains undefined, and there are limited data on its impact on antimicrobial stewardship.

METHODS

This retrospective study was conducted at a referral hospital in Taiwan from November 2019 to October 2022. Adult ICU patients with HAP/VAP who underwent FAPP testing were enrolled. Patient data, FAPP results, conventional microbiological testing results, and the real-world impact of FAPP results on antimicrobial therapy adjustments were assessed. Logistic regression was used to determine the predictive factors for bacterial detection by FAPP.

RESULTS

Among 592 respiratory specimens, including 564 (95.3%) endotracheal aspirate specimens, 19 (3.2%) expectorated sputum specimens and 9 (1.5%) bronchoalveolar lavage specimens, from 467 patients with HAP/VAP, FAPP testing yielded 368 (62.2%) positive results. Independent predictors for positive bacterial detection by FAPP included prolonged hospital stay (odds ratio [OR], 3.14), recent admissions (OR, 1.59), elevated C-reactive protein levels (OR, 1.85), Acute Physiology and Chronic Health Evaluation II scores (OR, 1.58), and septic shock (OR, 1.79). Approximately 50% of antimicrobial therapy for infections caused by Gram-negative bacteria and 58.4% for Gram-positive bacteria were adjusted or confirmed after obtaining FAPP results.

CONCLUSIONS

This study identified several factors predicting bacterial detection by FAPP in critically ill patients with HAP/VAP. More than 50% real-world clinical practices were adjusted or confirmed based on the FAPP results. Clinical algorithms for the use of FAPP and antimicrobial stewardship guidelines may further enhance its benefits.

High mortality of patients with severe pneumonia caused by respiratory syncytial virus, August 2021-June 2023, Taiwan

Among the 14 patients with respiratory syncytial virus pneumonia, the majority (n = 8, 57.1 %) were older than 65 years and had health care-associated pneumonia (57.1 %). Over 70 % (n = 10) of them exhibited bacterial co-infection, with a high proportion (64.3 %) requiring mechanical ventilation. The hospital mortality rate was 50 %.

Risk factors for prolonged mechanical ventilation in critically ill patients with influenza-related acute respiratory distress syndrome

BACKGROUND

Patients with influenza-related acute respiratory distress syndrome (ARDS) are critically ill and require mechanical ventilation (MV) support. Prolonged mechanical ventilation (PMV) is often seen in these cases and the optimal management strategy is not established. This study aimed to investigate risk factors for PMV and factors related to weaning failure in these patients.

METHODS

This retrospective cohort study was conducted by eight medical centers in Taiwan. All patients in the intensive care unit with virology-proven influenza-related ARDS requiring invasive MV from January 1 to March 31, 2016, were included. Demographic data, critical illness data and clinical outcomes were collected and analyzed. PMV is defined as mechanical ventilation use for more than 21 days.

RESULTS

There were 263 patients with influenza-related ARDS requiring invasive MV enrolled during the study period. Seventy-eight patients had PMV. The final weaning rate was 68.8% during 60 days of observation. The mortality rate in PMV group was 39.7%. Risk factors for PMV were body mass index (BMI) > 25 (kg/m2) [odds ratio (OR) 2.087; 95% confidence interval (CI) 1.006-4.329], extracorporeal membrane oxygenation (ECMO) use (OR 6.181; 95% CI 2.338-16.336), combined bacterial pneumonia (OR 4.115; 95% CI 2.002-8.456) and neuromuscular blockade use over 48 h (OR 2.8; 95% CI 1.334-5.879). In addition, risk factors for weaning failure in PMV patients were ECMO (OR 5.05; 95% CI 1.75-14.58) use and bacteremia (OR 3.91; 95% CI 1.20-12.69).

CONCLUSIONS

Patients with influenza-related ARDS and PMV have a high mortality rate. Risk factors for PMV include BMI > 25, ECMO use, combined bacterial pneumonia and neuromuscular blockade use over 48 h. In addition, ECMO use and bacteremia predict unsuccessful weaning in PMV patients.

Prediction of methicillin-resistant Staphylococcus aureus and carbapenem-resistant Klebsiella pneumoniae from flagged blood cultures by combining rapid Sepsityper MALDI-TOF mass spectrometry with machine learning

This study investigated combination of the Rapid Sepsityper Kit and a machine learning (ML)-based matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) approach for rapid prediction of methicillin-resistant Staphylococcus aureus (MRSA) and carbapenem-resistant Klebsiella pneumoniae (CRKP) from positive blood culture bottles. The study involved 461 patients with monomicrobial bloodstream infections. Species identification was performed using the conventional MALDI-TOF MS Biotyper system and the Rapid Sepsityper protocol. The data underwent preprocessing steps, and ML models were trained using preprocessed MALDI-TOF data and corresponding labels. The interpretability of the model was enhanced using SHapely Additive exPlanations values to identify significant features. In total, 44 S. aureus isolates comprising 406 MALDI-TOF MS files and 126 K. pneumoniae isolates comprising 1249 MALDI-TOF MS files were evaluated. This study demonstrated the feasibility of predicting MRSA among S. aureus and CRKP among K. pneumoniae isolates using MALDI-TOF MS and Sepsityper. Accuracy, area under the receiver operating characteristic curve, and F1 score for MRSA/methicillin-susceptible S. aureus were 0.875, 0.898 and 0.904, respectively; for CRKP/carbapenem-susceptible K. pneumoniae, these values were 0.766, 0.828 and 0.795, respectively. In conclusion, the novel ML-based MALDI-TOF MS approach enables rapid identification of MRSA and CRKP from flagged blood cultures within 1 h. This enables earlier initiation of targeted antimicrobial therapy, reducing deaths due to sepsis. The favourable performance and reduced turnaround time of this method suggest its potential as a rapid detection strategy in clinical microbiology laboratories, ultimately improving patient outcomes.

Direct prediction of carbapenem-resistant, carbapenemase-producing, and colistin-resistant Klebsiella pneumoniae isolates from routine MALDI-TOF mass spectra using machine learning and outcome evaluation

The objective of this study was to develop a rapid prediction method for carbapenem-resistant Klebsiella pneumoniae (CRKP) and colistin-resistant K. pneumoniae (ColRKP) based on routine MALDI-TOF mass spectrometry (MS) results in order to formulate a suitable and rapid treatment strategy. In total, 830 CRKP and 1,462 carbapenem-susceptible K. pneumoniae (CSKP) isolates were collected; 54 ColRKP isolates and 1,592 colistin-intermediate K. pneumoniae (ColIKP) isolates were also included. Routine MALDI-TOF MS, antimicrobial susceptibility testing, NG-Test CARBA 5, and resistance gene detection were followed by machine learning (ML). Using the ML model, the accuracy and area under the curve for differentiating CRKP and CSKP were 0.8869 and 0.9551, and those for ColRKP and ColIKP were 0.8361 and 0.8447, respectively. The most important MS features of CRKP and ColRKP were m/z 4520-4529 and m/z 4170-4179, respectively. Of the CRKP isolates, MS m/z 4520-4529 was a potential biomarker for distinguishing KPC from OXA, NDM, IMP, and VIM. Of the 34 patients who received preliminary CRKP ML prediction results (by texting), 24 (70.6%) were confirmed to have CRKP infection. The mortality rate was lower in patients who received antibiotic regimen adjustment based on the preliminary ML prediction (4/14, 28.6%). In conclusion, the proposed model can provide rapid results for differentiating CRKP and CSKP, as well as ColRKP and ColIKP. The combination of ML-based CRKP with preliminary reporting of results can help physicians alter the regimen approximately 24 h earlier, resulting in improved survival of patients with timely antibiotic intervention.

Polysomnography Is an Important Method for Diagnosing Pediatric Sleep Problems: Experience of One Children’s Hospital

In this study, we collected and analyzed polysomnography (PSG) data to investigate the value of PSG in diagnosing sleep problems in children. The results of PSG studies of children (<18 years old) with sleep problems conducted from April 2015 to May 2017 at a children’s hospital in Taiwan were collected and analyzed retrospectively. Data for 310 patients (209 males and 101 females) who underwent PSG were collected. The final diagnoses were as follows: obstructive sleep apnea in 159 (51.3%), snoring in 81 (26.4%), limb movement sleep disorder in 25 (8.1%), hypersomnias in 12 (3.9%), central apnea in 8 (2.9%), enuresis in 7 (2.3%), bruxism in 5 (1.6%), sleep terrors in 5 (1.6%), narcolepsy in 3 (1.0%), sleep seizures in 3 (1.0%), sleep walking in 1 (0.3%), and insomnia in 1 (0.3%). PSG may help detect significant sleep-related problems in children and is useful for making therapeutic decisions regarding children. Obstructive sleep apnea syndrome (OSAS) was the primary sleep problem for most of the children (51.3%); however, only 7.4% of them underwent surgery for OSAS. We therefore suggest that children with sleep problems should undergo PSG.

Comparison of prone positioning and extracorporeal membrane oxygenation in acute respiratory distress syndrome: A multicenter cohort study and propensity-matched analysis

Background/Purpose

Both prone positioning and extracorporeal membrane oxygenation (ECMO) are used as rescue therapies for severe hypoxemia in patients with acute respiratory distress syndrome (ARDS). This study compared outcomes between patients with severe influenza pneumonia-related ARDS who received prone positioning and those who received ECMO.

Methods

This retrospective cohort study included eight tertiary referral centers in Taiwan. All patients who were diagnosed as having influenza pneumonia-related severe ARDS were enrolled between January and March 2016. We collected their demographic data and prone positioning and ECMO outcomes from medical records.

Results

In total, 263 patients diagnosed as having ARDS were included, and 65 and 53 of them received prone positioning and ECMO, respectively. The baseline PaO₂/FiO₂ ratio, Acute Physiology and Chronic Health Evaluation II score and Sequential Organ Failure Assessment score did not significantly differ between the two groups. The 60-day mortality rate was significantly higher in the ECMO group than in the prone positioning group (60% vs. 28%, p = 0.001). A significantly higher mortality rate was still observed in the ECMO group after propensity score matching (59% vs. 36%, p = 0.033). In the multivariate Cox regression analysis, usage of prone positioning or ECMO was the single independent predictor for 60-day mortality (hazard ratio: 2.177, p = 0.034).

Conclusion

While the patients receiving prone positioning had better outcome, the causality between prone positioning and the prognosis is unknown. However, the current data suggested that patients with influenza-related ARDS may receive prone positioning before ECMO support.

Renal Replacement Therapy in Patients with Influenza Pneumonia Related Acute Respiratory Distress Syndrome

Acute kidney injury (AKI) requiring renal replacement therapy (RRT) increases the mortality of acute respiratory distress syndrome (ARDS) patients. The aim of this study was to investigate the outcomes and predictors of RRT in patients with influenza pneumonia-related ARDS. This retrospective cohort study includes patients from eight tertiary referral centers in Taiwan between January and March 2016, and all 282 patients with influenza pneumonia-related ARDS were enrolled. Thirty-four patients suffered from AKI requiring RRT, while 16 patients had underlying end stage renal disease (ESRD). The 30- and 60-day mortality rates were significantly higher in patients with AKI requiring RRT compared with those not requiring RRT (50.0% vs. 19.8%, p value < 0.001; 58.8% vs. 27.2%, p value = 0.001, respectively), but the patients with ESRD had no significant difference in mortality (12.5% vs. 19.8%, p value = 0.744; 31.3% vs. 27.2%, p value = 0.773, respectively). The predictors for AKI requiring RRT included underlying chronic liver disease and C-reactive protein. The mortality predictors for patients with AKI requiring RRT included the pneumonia severity index, tidal volume, and continuous renal replacement therapy. In this study, patients with influenza pneumonia-related ARDS with AKI requiring RRT had significantly higher mortality compared with other patients.

[Applying Team Resource Management to Reduce the Urinary Catheter Usage Rate in Our Intensive Care Unit]

BACKGROUND & PROBLEMS

According to the literature, 74%-84% of patients in adult critical care units have an indwelling catheter. The majority of medical and healthcare infections are urinary tract infections, which are related to urinary catheter usage. Furthermore, critical infections may cause bacteremia, which increases the risk of mortality. Prior to this project, over three-quarters (78.7%) of patients in our unit used a urinary catheter, which is a rate that is higher than all other intensive care units of our hospital's internal medicine department. Due to Foley placement, removal and care of catheters requires collaboration of teamwork. Thus, the concept of team resource management may be applied to improve the situation.

PURPOSE

The aim of this study was to reduce the urinary catheter usage rate in our intensive care unit to less than 69.3%.

RESOLUTIONS

This project summarized the reasons for the high catheter usage rate in this unit on 2017/1/3 and implemented several approaches to improve the situation from 2017/2/1 to 2017/6/30. These approaches included affixing reminder labels to indwelling catheters, using an ultrasound bladder scanner as a substitute for intermittent catheterization, evaluating indwelling catheters, establishing flow planning for post-catheter removal, holding cross-team meetings, and adopting a reward system. During the improvement period, we held collaborative conference meetings weekly to discuss solutions, evaluate end-of-the-month progress, and set reward policies.

RESULTS

We lowered the average urinary catheter usage rate from 78.7% on 2017/3/1 to 57.8% on 2017/6/30, achieving a 26.5% reduction in catheter usage.

CONCLUSIONS

This project both effectively reduced the unnecessary use of urinary catheters and significantly strengthened team spirit in our unit, thus improving the quality of medical care provided.

Risk factor analysis of nosocomial lower respiratory tract infection in influenza-related acute respiratory distress syndrome

Background:

Patients with severe influenza-related acute respiratory distress syndrome (ARDS) have high morbidity and mortality. Moreover, nosocomial lower respiratory tract infection (NLRTI) complicates their clinical management and possibly worsens their outcomes. This study aimed to explore the clinical features and impact of NLRTI in patients with severe influenza-related ARDS.

Methods:

This was an institutional review board approved, retrospective, observational study conducted in eight medical centers in Taiwan. From January 1 to March 31 in 2016, subjects were enrolled from intensive care units (ICUs) with virology-proven influenza pneumonia, while all of those patients with ARDS requiring invasive mechanical ventilation and without bacterial community-acquired pneumonia (CAP) were analyzed. Baseline characteristics, critical-illness data and clinical outcomes were recorded.

Results:

Among the 316 screened patients with severe influenza pneumonia, 250 with acute respiratory failure requiring intubation met the criteria of ARDS, without having bacterial CAP. Among them, 72 patients developed NLRTI. The independent risk factors for NLRTI included immunosuppressant use before influenza infection [odds ratio (OR), 5.669; 95% confidence interval (CI), 1.770–18.154], extracorporeal membrane oxygenation (ECMO) use after ARDS (OR, 2.440; 95% CI, 1.214–4.904) and larger corticosteroid dosage after ARDS (OR, 1.209; 95% CI, 1.038–1.407). Patients with NLRTI had higher in-hospital mortality and longer ICU stay, hospitalization and duration on mechanical ventilation.

Conclusion:

We found that immunosuppressant use before influenza infection, ECMO use, and larger steroid dosage after ARDS independently predict NLRTI in influenza-related ARDS. Moreover, NLRTI results in poorer outcomes in patients with severe influenza.

The reviews of this paper are available via the supplemental material section.

Impact of corticosteroid treatment on clinical outcomes of influenza-associated ARDS: a nationwide multicenter study

Background

Corticosteroid treatment has been widely used in the treatment of septic shock, influenza, and ARDS, although some previous studies discourage its use in severe influenza patients. This multicenter retrospective cohort study conducted in the intensive care units (ICUs) of eight medical centers across Taiwan aims to determine the real-world status of corticosteroid treatment in patients with influenza-associated acute respiratory distress syndrome (ARDS) and its impact on clinical outcomes. Between October 2015 and March 2016, consecutive ICU patients with virology-proven influenza infections who fulfilled ARDS and received invasive mechanical ventilation were enrolled. The impact of early corticosteroid treatment (≥ 200 mg hydrocortisone equivalent dose within 3 days after ICU admission, determined by a sensitivity analysis) on hospital mortality (the primary outcome) was assessed by multivariable logistic regression analysis, and further confirmed in a propensity score-matched cohort.

Results

Among the 241 patients with influenza-associated ARDS, 85 (35.3%) patients receiving early corticosteroid treatment had similar baseline characteristics, but a significantly higher hospital mortality rate than those without early corticosteroid treatment [43.5% (37/85) vs. 19.2% (30/156), p < 0.001]. Early corticosteroid treatment was independently associated with increased hospital mortality in overall patients [adjusted odds ratio (95% CI) = 5.02 (2.39–10.54), p < 0.001] and in all subgroups. Earlier treatment and higher dosing were associated with higher hospital mortality. Early corticosteroid treatment was associated with a significantly increased odds of subsequent bacteremia [adjusted odds ratio (95% CI) = 2.37 (1.01–5.56)]. The analyses using a propensity score-matched cohort showed consistent results.

Conclusions

Early corticosteroid treatment was associated with a significantly increased hospital mortality in adult patients with influenza-associated ARDS. Earlier treatment and higher dosing were associated with higher hospital mortality. Clinicians should be cautious while using corticosteroid treatment in this patient group.

Using a machine learning approach to predict mortality in critically ill influenza patients: a cross-sectional retrospective multicentre study in Taiwan

OBJECTIVES

Current mortality prediction models used in the intensive care unit (ICU) have a limited role for specific diseases such as influenza, and we aimed to establish an explainable machine learning (ML) model for predicting mortality in critically ill influenza patients using a real-world severe influenza data set.

STUDY DESIGN

A cross-sectional retrospective multicentre study in Taiwan SETTING: Eight medical centres in Taiwan.

PARTICIPANTS

A total of 336 patients requiring ICU-admission for virology-proven influenza at eight hospitals during an influenza epidemic between October 2015 and March 2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

We employed extreme gradient boosting (XGBoost) to establish the prediction model, compared the performance with logistic regression (LR) and random forest (RF), demonstrated the feature importance categorised by clinical domains, and used SHapley Additive exPlanations (SHAP) for visualised interpretation.

RESULTS

The data set contained 76 features of the 336 patients with severe influenza. The severity was apparently high, as shown by the high Acute Physiology and Chronic Health Evaluation II score (22, 17 to 29) and pneumonia severity index score (118, 88 to 151). XGBoost model (area under the curve (AUC): 0.842; 95% CI 0.749 to 0.928) outperformed RF (AUC: 0.809; 95% CI 0.629 to 0.891) and LR (AUC: 0.701; 95% CI 0.573 to 0.825) for predicting 30-day mortality. To give clinicians an intuitive understanding of feature exploitation, we stratified features by the clinical domain. The cumulative feature importance in the fluid balance domain, ventilation domain, laboratory data domain, demographic and symptom domain, management domain and severity score domain was 0.253, 0.113, 0.177, 0.140, 0.152 and 0.165, respectively. We further used SHAP plots to illustrate associations between features and 30-day mortality in critically ill influenza patients.

CONCLUSIONS

We used a real-world data set and applied an ML approach, mainly XGBoost, to establish a practical and explainable mortality prediction model in critically ill influenza patients.

Air Pollutants Are Associated With Obstructive Sleep Apnea Severity in Non-Rapid Eye Movement Sleep

STUDY OBJECTIVES

The relationship between seasonal variation of obstructive sleep apnea and ambient temperature and pollutants has been inconsistent in previous studies. It is also unknown whether the seasonal variation in apnea-hypopnea index influences continuous positive airway pressure treatment dose. This study aims to examine the seasonality of obstructive sleep apnea and continuous positive airway pressure treatment, and the association between air pollutants and apnea-hypopnea index in adults with different sleep apnea severity during different sleep stages.

METHODS

Polysomnography of 5,413 patients referred to one sleep center during 2008-2015 were examined retrospectively. Ambient conditions and air pollutants levels were collected from the official air condition surveillance database. Cosinor analysis was used to examine seasonal variances. The general linear model was used to examine associations between air conditions and apnea-hypopnea index adjusted for seasonality. Models for apnea-hypopnea index in different sleep stages, sex groups, and obstructive sleep apnea severity groups were analyzed separately.

RESULTS

Seasonal variations for continuous positive airway pressure treatment were not significant. Particulate matter less than or equal to 10 μm, ozone, sulfur dioxide, and relative humidity were associated with apnea-hypopnea index only in patients with severe obstructive sleep apnea. The association was significant only in non-rapid eye movement sleep.

CONCLUSIONS

An adjustment for continuous positive airway treatment dose by season is not warranted. Protection for air pollutant-vulnerable groups should be provided. The exact mechanism of the associations between apnea-hypopnea index and air conditions only in non-rapid eye movement sleep must be clarified.

Predictors of survival in patients with influenza pneumonia-related severe acute respiratory distress syndrome treated with prone positioning

Background

Patients with influenza complicated with pneumonia are at high risk of rapid progression to acute respiratory distress syndrome (ARDS). Prone positioning with longer duration and lung-protective strategies might reduce the mortality level in ARDS. The aim of this study is to investigate the survival predictors of prone positioning in patients with ARDS caused by influenza pneumonia.

Methods

This retrospective study was conducted by eight tertiary referral centers in Taiwan. From January 1 to March 31 in 2016, all of the patients in intensive care units with virology-proven influenza pneumonia were collected, while all of those patients with ARDS and receiving prone positioning were enrolled. Demographic data, laboratory examinations, management records, ventilator settings and clinical outcomes were collected for analysis.

Results

During the study period, 336 patients with severe influenza pneumonia were screened and 263 patients met the diagnosis of ARDS. Totally, 65 patients receiving prone positioning were included for analysis. The 60-day survivors had lower Acute Physiology and Chronic Health Evaluation (APACHE) II score, pneumonia severity index (PSI), creatinine level and lower rate of receiving renal replacement therapy than non-survivors (22.4 ± 8.5 vs. 29.2 ± 7.4, p = 0.003; 106.6 ± 40.9 vs. 135.3 ± 48.6, p = 0.019; 1.2 ± 0.9 mg/dL vs. 3.1 ± 3.6 mg/dL, p = 0.040; and 4% vs. 42%, p < 0.005). Multivariate Cox regression analysis identified PSI (hazard ratio 1.020, 95% confidence interval 1.009–1.032; p < 0.001), renal replacement therapy (hazard ratio 6.248, 95% confidence interval 2.245–17.389; p < 0.001), and increase in dynamic driving pressure (hazard ratio 1.372, 95% confidence interval 1.095–1.718; p = 0.006) which were independent predictors associated with 60-day mortality.

Conclusions

In the present study, in evaluating the effect of prone positioning in patients with influenza pneumonia-related ARDS, pneumonia severity index, renal replacement therapy and increase in dynamic driving pressure were associated with 60-day mortality in patients with influenza pneumonia-related ARDS receiving prone positioning.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0440-4) contains supplementary material, which is available to authorized users.

First tidal volume greater than 8 mL/kg is associated with increased mortality in complicated influenza infection with acute respiratory distress syndrome

BACKGROUNDS

Severe influenza infection causes substantial morbidity and mortality worldwide and remains an important threat to global health. This study addressed factors related to treatment outcomes in subjects of complicated influenza infection with acute respiratory distress syndrome (ARDS) during the Taiwan epidemic in the Spring of 2016.

METHODS

This is a retrospective study conducted by Taiwan Severe Influenza Research Consortium (TSIRC), including eight tertiary referral medical centers. Patients with virology-proven influenza infection admitted to intensive care unit (ICU) between January and March 2016 were included for analysis.

RESULTS

We identified 263 patients with complicated influenza infection who fulfilled ARDS criteria; the mean age was 59.8 ± 14.6 (years), and 66.1% (166/263) were male. Type A influenza (77.9%, 205/263) virus was the main pathogen during this epidemic. The 30-day mortality rate was 23.2% (61/263). The mean tidal volume (V_T) in the first three days after intubation was greater than 8 mL/kg of predicted body weight (PBW). Patients whose first measured V_T was >8 mL/kg PBW had an increased 30-day mortality (p = 0.04, log-rank test). In a multivariate Cox proportional hazard regression model, an increase of 1 mL/kg PBW of first V_T was associated with 26.1% increase in 30-day mortality (adjusted hazard ratio 1.261, 95% confidence interval [CI] 1.072-1.484, p < 0.01).

CONCLUSION

First tidal volume, shortly after intubation, greater than 8 mL/kg PBW is an independent risk factor for mortality in complicated influenza infection with ARDS. Timely recognition of ARDS with strict adherence to protective ventilation strategy of lowering V_T may be important in reducing mortality.

Risk of obstructive sleep apnoea in patients with rheumatoid arthritis: a nationwide population-based retrospective cohort study

OBJECTIVE

Sleep disorders are prevalent medical disorders in patients with rheumatoid arthritis (RA). However, whether patients with RA are at an increased risk of developing obstructive sleep apnoea (OSA) is unclear.

DESIGN

Using population-based retrospective cohort study to examine the risk of OSA in patients with RA.

SETTING

We used claims data of the National Health Insurance Research Database (NHIRD) of Taiwan.

PARTICIPANTS

We identified a RA cohort with 33 418 patients newly diagnosed in 2000-2010 and a randomly selected non-RA comparison cohort with 33 418 individuals frequency matched by sex, age and diagnosis year.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incident OSA was estimated by the end of 2011. The HRs of OSA were calculated using the Cox proportional hazards regression analysis.

RESULTS

The overall incidence rate of OSA was 75% greater in the RA cohort than in the non-RA cohort (3.04 vs 1.73/10 000 person-years, p<0.001), with an adjusted HR (aHR) of 1.75 (95% CI 1.18 to 2.60). Stratified analyses by sex, age group and comorbidity revealed that the incidence rates of OSA associated with RA were higher in all subgroups.

CONCLUSIONS

This population-based retrospective cohort study suggested that patients with RA should be monitored for the risk of developing OSA.

The modified SAVE score: predicting survival using urgent veno-arterial extracorporeal membrane oxygenation within 24 hours of arrival at the emergency department

Background

Although many risk models have been tested in patients who undergo extracorporeal membrane oxygenation, few have been assessed for patients who received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support in the emergency department (ED). This study aimed to successfully predict outcomes of patients with cardiac or noncardiac failure who received VA-ECMO in the ED within 24 hours of arrival at the ED.

Method

This retrospective, observational cohort study included 154 patients, who were classified as cardiac (n = 127) and noncardiac (n = 27) patients and received VA-ECMO within 24 hours after arrival at the China Medical University Hospital ED in Taiwan between January 2009 and September 2014. We recorded mechanical ventilation settings, arterial blood gases, laboratory parameters including plasma lactate level, requirement of catecholamines, and risk scores at time of ECMO initiation. ECMO and mechanical ventilation support duration, length of stay in the hospital, and 90-day mortality data were also examined.

Results

The overall mortality rate was 64.9 %. We used “survival after veno-arterial ECMO (SAVE)” scores to assess survival prediction in survival and nonsurvival groups, which was statistically different (–3.2 vs. –8.3, p <0.001). According to multivariate Cox proportional regression of survival, lactate (hazard ratio [HR] = 1.01, 95 % confidence interval [CI], 1.01–1.01, p <0.001) and SAVE score (HR = 0.92, [95 % CI, 0.88–0.96], p = 0.001) were independent predictors of outcome. Excellent discrimination (area under curve (AUC) = 0.843) was observed when lactate and SAVE score were combined, which we referred to as “the modified SAVE score.”

Conclusions

Modified SAVE scores improved outcome prediction for patients who underwent urgent VA-ECMO in the ED.

The relationships of sleep apnea, hypertension, and resistant hypertension on chronic kidney disease

Hypertension, blood pressure variation, and resistant hypertension have close relations to sleep apnea, which lead to target organ damage, including the kidney. The complex relationships between sleep apnea and blood pressure cause their interactions with chronic kidney disease ambiguous. The aim of the study was to elucidate the separate and joint effects of sleep apnea, hypertension, and resistant hypertension on chronic kidney disease. A cross-sectional study was done to see the associations of sleep apnea, hypertension, and resistant hypertension with chronic kidney disease in 998 subjects underwent overnight polysomnography without device-therapy or surgery for their sleep-disordered breathing. Multivariate logistic regression was used to analyze the severity of SA, hypertension stage, resistant hypertension, and their joint effects on CKD. The multivariable relative odds (95% CI) of chronic kidney disease for the aged (age ≥65 years), severe sleep apnea, stage III hypertension, and resistant hypertension were 3.96 (2.57-6.09) (P < 0.001), 2.28 (1.13-4.58) (P < 0.05), 3.55 (1.70-7.42) (P < 0.001), and 9.42 (4.22-21.02) (P < 0.001), respectively. In subgroups analysis, the multivariable relative odds ratio of chronic kidney disease was highest in patients with both resistant hypertension and severe sleep apnea [13.42 (4.74-38.03)] (P < 0.001). Severe sleep apnea, stage III hypertension, and resistant hypertension are independent risk factors for chronic kidney disease. Patients with both severe sleep apnea and resistant hypertension have the highest risks.

The Contribution of Interleukin-10 Promoter Genotypes to Susceptibility to Asthma in Adults

AIM

Accumulating evidence suggests that inflammatory processes play a role in asthma etiology, and interleukin-10 (IL10) is an important immunosuppressive cytokine. The present study aimed to evaluate the contribution of IL10 promoter A-1082G (rs1800896), T-819C (rs3021097), A-592C (rs1800872) genetic polymorphisms to the risk of asthma in Taiwan.

MATERIALS AND METHODS

Associations of three IL10 polymorphic genotypes with risk of asthma were investigated among 198 patients with asthma and 453 non-asthmatic healthy controls, by polymerase chain reaction-restriction fragment length polymorphism genotyping method.

RESULTS

The results showed that the percentages of TT, TC and CC for IL-10 T-819C genotypes were differentially represented at 63.1%, 32.3% and 4.6%, respectively, in the patient group and 53.0%, 36.4% and 10.6%, respectively, in the healthy control group (p for trend=0.0114). The CC genotype carriers were at lower risk for asthma (odds ratio=0.36, 95% confidence interval=0.17-0.76, p=0.0055). There was no difference in the distribution of A-1082G or A-592C genotype between the asthma and non-asthma groups. The protective effects of the CC genotype were obvious among males, but not females, and those aged 25 up to 40 years but not those aged over 40 years.

CONCLUSION

The CC genotype of IL10 T-819C compared to the TT genotype may have a protective effect on asthma risk in younger adults (25-40 years old), and males in Taiwan.

Contribution of Genotype of DNA Double-strand Break Repair Gene XRCC3, Gender, and Smoking Behavior to Lung Cancer Risk in Taiwan

AIM

The present study evaluated the contribution of genotype of X-ray repair cross-complementing group 3 (XRCC3), age, gender, and smoking to lung cancer risk in Taiwan.

MATERIALS AND METHODS

A total of 358 patients with lung cancer and 716 controls were investigated for their XRCC3 rs1799794, rs45603942, rs861530, rs3212057, rs1799796, rs861539, rs28903081 genotype, epidemiological and clinical data for association and gene-Iifestyle interactions.

RESULTS

The results showed that CT and TT genotypes of XRCC3 rs861539 were associated with increased lung cancer risk (odds ratio=1.81, 95% confidence interval=1.18-2.78; odds ratio=3.43, 95% confidence interval=1.12-10.60, respectively). This polymorphism also influenced lung cancer susceptibility in males and smokers (p=0.0017 and 0.0045, respectively).

CONCLUSION

The T allele of XRCC3 rs861539 contributes to increased risk of lung cancer in Taiwanese, particularly those who are male and smokers.

Sleep disorders increase risk of subsequent erectile dysfunction in individuals without sleep apnea: a nationwide population-base cohort study

BACKGROUND

Sleep disorders (SD) and erectile dysfunction (ED) both play crucial roles in quality of life and have received increasing attention in the general population and among physicians.

METHODS

This study investigated the risk of ED in people diagnosed with SD compared with that in age- and sex-matched unaffected people. This longitudinal, nationwide, population-based cohort study was conducted using data in the Taiwan National Health Insurance Research Database (NHIRD) from January 1998 to December 2011. The sample consisted of 603 people with sleep apnea, 17,182 people with non-apnea SD, and 35,570 matched comparisons as controls. A Cox proportional hazard regression was used to compute the risk of ED in people with SD relative to that in people without SD.

RESULTS

The ED incidences were 9.44-fold higher (95% CI 6.49-13.7) in the sleep apnea cohort and 3.72-fold higher (95% CI 3.13-4.41) in the non-apnea SD cohort than in the control cohort, respectively, after age, sex, and comorbidities were adjusted for. The incidence of ED was higher in younger adults (adjusted hazard ratio (HR), 10.4 (95% CI 5.93-18.4) in the sleep apnea cohort and adjusted HR, 4.20 (95% CI 3.07-5.76) in non-apnea SD cohort) and those using benzodiazepine (adjusted HR, 9.69 (95% CI 5.48-10.6) in the sleep apnea cohort and adjusted HR, and 3.83 (95% CI 3.20-4.59) in the non-apnea SD cohort).

CONCLUSION

This nationwide population-based cohort study provides evidence that people with SD, particularly those with sleep apnea, exhibit an increased risk of subsequent ED.

Diagnostic pitfalls of discriminating lymphoma-associated effusions

High serum lactate dehydrogenase (LDH) level, immunologic defects, enlarged mediastinal lymph nodes, and frequent hydration and diuresis in lymphoma patients may affect the development of pleural effusion (PE). The study was to assess the clinical utility of "Light criteria" and the "recommended algorithm for investigating PEs" in patients with lymphoma.The characteristics of 126 PEs of lymphoma patients who underwent diagnostic thoracentesis between January 1, 2003, and April 30, 2012, were reviewed. Using Light criteria, 29 (23%) PEs were incorrectly classified. The sensitivity for exudates in Light criteria was 88% and the specificity was only 44%. In 32 transudates, PE LDH correlated with blood LDH concentration (P < 0.001, r = 0.66). Nine transudates were misclassified as exudates (50%; 9/18) just due to PE LDH more than two-thirds the upper limits. Among the 56 bilateral PEs, 33 (59%) were exudates. Ten (63%) polymorphonuclear (PMN)-predominant exudative PEs were malignant. Infective PEs were often mononuclear (67%) rather than PMN predominant.When a patient has lymphoma with either unilateral or bilateral PE, thoracentesis for microbiological testing and cytology is imperative. Carefully clinical correlation in addition to the result from Light criteria and differential cell count is essential for prompt management.

Polysomnographic predictors of persistent continuous positive airway pressure adherence in patients with moderate and severe obstructive sleep apnea

Extensive use of continuous positive airway pressure (CPAP) has positive clinical benefits for most patients with obstructive sleep apnea (OSA). However, patient adherence is a major limiting factor to the effectiveness of CPAP treatment. This study determined the potential and quantifiable factors affecting the willingness of patients with OSA to undertake CPAP treatment by comparing the polysomnographic parameters recorded during diagnosis and titration. Patients with moderate and severe OSA who attended diagnostic polysomnography (PSG) and CPAP titration at the sleep center of China Medical University Hospital (CMUH) were included in the study. A total of 312 patients were divided into persistent users and nonusers of CPAP according to their use of in-home CPAP following titration and a 7-day CPAP trial. Multivariate logistic regression analyses were used to define the potential polysomnographic predictors of persistent CPAP adherence, and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Most patients were men older than 50 years who were overweight or obese. Among the patients, 146 (46.8%) became persistent CPAP users. A 10% improvement of oxygen desaturation index (ODI) and a 10% increment in deep sleep percentage increased the chance of persistent CPAP use 1.18-fold and 1.07-fold, respectively. In addition, the improved ODI and deep sleep during CPAP titration increased the chance of persistent CPAP user. The polysomnographic parameters obtained from diagnosis and during titration can facilitate the prediction of persistent CPAP use.

Diagnostic impact of color Doppler ultrasound-guided core biopsy on fine-needle aspiration of anterior mediastinal masses

Although lymphoma and thymoma are common etiologies of anterior mediastinal masses (AMMs), smaller percentages and numbers of patients with these diseases have been enrolled in previous ultrasound-guided biopsy studies. To date, there has been no study of color Doppler sonographic features to support the differentiation of AMMs. For this retrospective cohort study, a search of the database of the China Medical University Hospital using the clinical coding "ultrasound-guided biopsy" was conducted for the period December 2003 to February 2013. We selected patients diagnosed with AMMs (not cysts) using radiographic records. This search yielded a list of 80 cases. Real-time ultrasound-guided core needle biopsy (CNB) was performed in all but 5 patients without a sufficient safety range. In 89% (67/75) of these ultrasound-guided CNB cases, the diagnostic accuracy achieved subclassification. Fine-needle aspiration cytology achieved subclassification in only 10% of cases. On color Doppler sonography, 71% of lymphomas were characterized as "rich vascular with central/crisscross collocations" and 29% as "avascular or localized/scattered peripheral vessels." However, decreased proportions of "rich vascular with central/crisscross collocations" were found in lung cancer (4% [1/23], odds ratio = 0.018, 95% confidence interval: 0.002-0.154, p < 0.001) and thymoma/thymic carcinoma (25% [4/16]; odds ratio = 0.133, 95% confidence interval: 0.035-0.514, p = 0.003) compared with the lymphoma group. We conclude that the vessels in lymphoma AMMs have specific patterns on color Doppler sonography. Ultrasound-guided CNB of AMMs had an accuracy of ≤ 89% in diagnosis and subclassification. Fine-needle aspiration cytology itself cannot aid in the diagnosis. Color Doppler sonographic evaluation of AMMs followed by real-time CNB is a more efficient method.

Interleukin-10 (IL-10) promoter genotypes are associated with lung cancer risk in Taiwan males and smokers

Interleukin-10 (IL-10) is an immunosuppressive cytokine involved in carcinogenesis via immune escape. The present study aimed at evaluating the contribution of IL-10 promoter A-1082G (rs1800896), T-819C (rs3021097), A-592C (rs1800872) genetic polymorphisms to the risk of lung cancer in Taiwan. Associations of three IL-10 polymorphic genotypes with lung cancer risk were investigated among 358 lung cancer patients and 716 age- and gender-matched healthy controls. In addition, the genetic-lifestyle interaction was also examined. The results showed that the percentages of TT, TC and CC for IL-10 T-819C genotypes were differentially represented as 59.2%, 35.8% and 5.0% in the lung-cancer patient group and 52.0%, 37.0% and 11.0% in the non-cancer control group, respectively (p for trend=0.0025). The CC genotype carriers were of lower risk for lung cancer (OR=0.4, 95% CI=0.23-0.69, p=0.0005). Further stratification of the population by gender and smoking behavior showed that the IL-10 T-819C genotype conducted a protective effect on lung cancer susceptibility, which was obvious among males and smokers (p=0.0003 and 0.0004, respectively). The CC and TC genotypes of IL-10 T-819C compared to the TT genotype may have a protective effect on lung cancer risk in Taiwan, particularly among males and smokers.

Genotype of DNA double-strand break repair gene XRCC7 is associated with lung cancer risk in Taiwan males and smokers

AIM

The present study aimed to evaluate the contribution of X-ray repair cross-complementing group 7 (XRCC7) G6721T (rs7003908) genetic polymorphism and smoking habit on the risk of lung cancer in Taiwanese.

MATERIALS AND METHODS

In this hospital-based case-control study, association of single nucleotide polymorphism XRCC7 G6721T with lung cancer risk were examined among 358 patients with lung cancer and 716 age- and gender-matched healthy controls. The genetic-lifestyle interaction was also investigated.

RESULTS

The results showed that the percentages of TT, GT and GG genotypes for XRCC7 G6721T were differentially distributed as 60.9%, 34.9% and 4.2% in the group of patients with lung cancer and 48.7%, 43.3% and 8.0% in the non-cancer control group, respectively (p=3.6*10(-7)). We further stratified the populations by gender and smoking behavior to investigate their combinatorial effects with XRCC7 G6721T genotype on lung cancer risk. The results showed that the GG genotype of XRCC7 G6721T had a protective effect on lung cancer susceptibility which was obvious among males and smokers (p=2.2×10(-4) and 3.1×10(-4), respectively).

CONCLUSION

The GG and GT genotypes of XRCC7 rs7003908 compared to the TT genotype had a protective effect on lung cancer risk in Taiwan, particularly among males and smokers.

Effects of ataxia telangiectasia mutated (ATM) genotypes and smoking habits on lung cancer risk in Taiwan

AIM

The study aimed to evaluate the association and interaction of ataxia telangiectasia mutated (ATM) genetic polymorphisms with lung cancer risk in Taiwan, where lung cancer is the primary cause of cancer-related death.

MATERIALS AND METHODS

In this hospital-based matched case-control study, associations of up to seven ATM single nucleotide polymorphisms (rs600931, rs652311, rs227060, rs228589, rs227092, rs624366 and rs189037) with lung cancer risk were investigated among Taiwanese. In this study, 358 lung cancer patients and 716 age- and gender-matched healthy controls were genotyped and the genetic-lifestyle interaction were analyzed.

RESULTS

The results showed that the percentages of GG, AG and AA for ATM rs652311 genotypes were significantly different at 34.6%, 48.9% and 16.5% in the lung cancer patient group and 39.9%, 51.0% and 9.1% in non-cancer control group, respectively. We further analyzed the genetic-lifestyle effects on lung cancer risk and found that the contribution of ATM rs652311 A allele-bearing genotypes to lung cancer susceptibility was enhanced in the cigarette smokers and not enhanced in the non-smokers (p=0.0045 and 0.2758, respectively).

CONCLUSION

Our results provide evidence that the A allele of ATM rs652311 may be associated with lung cancer risk, and may enhance the effects of smoking habit on lung cancer development.

The contribution of DNA apurinic/apyrimidinic endonuclease genotype and smoking habit to Taiwan lung cancer risk

To evaluate the association and interaction of genotypic polymorphism the gene for DNA-apurinic/apyrimidinic endonuclease (APEX1) with personal smoking habit and lung cancer risk in Taiwan, the polymorphic variants of APEX1, Asp(148)Glu (rs1130409), were analyzed in association with lung cancer risk, and their joint effect with personal smoking habits on lung cancer susceptibility was discussed. In this hospital-based case-control study, 358 patients with lung cancer and 716 cancer-free controls, frequency-matched by age and sex, were recruited and genotyped by polymerase chain reaction and restriction fragment length polymorphism (PCR-RFLP). The results showed that the percentages of TT, TG and GG APEX1 Asp(148)Glu genotypes were not significantly different at 43.0%, 41.1% and 15.9% in the lung cancer patient group and 39.9%, 46.1% and 14.0% in non-cancer control group, respectively. We further analyzed the genetic-lifestyle effects on lung cancer risk and found the contribution of APEX1 Asp(148)Glu genotypes to lung cancer susceptibility was neither enhanced in the cigarette smokers nor in the non-smokers (p=0.3550 and 0.8019, respectively). Our results provide evidence that the non-synonymous polymorphism of APEX1 Asp(148)Glu may not be directly associated with lung cancer risk, nor enhance the effects of smoking habit on lung cancer development.

Diffuse optical multipatch technique for tissue oxygenation monitoring: clinical study in intensive care unit

Diffuse optical multipatch technique is used to assess spatial variations in absorption and scattering in biological tissue, by monitoring changes in the concentration of oxyhemoglobin and deoxyhemoglobin. In our preliminary study, the temporal tracings of tissue oxygenation are measured using diffuse optical multipatch measurement and a venous occlusion test, employing normal subjects and ICU patients suffering from sepsis and heart failure. In experiments, obvious differences in tissue oxygenation signals were observed among all three groups. This paper discusses the physiological relevance of tissue oxygenation with respect to disease.

Differences in pulse spectrum analysis between atopic dermatitis and nonatopic healthy children

OBJECTIVES

Atopic dermatitis (AD) is a common allergy that causes the skin to be dry and itchy. It appears at an early age, and is closely associated with asthma and allergic rhinitis. Thus, AD is an indicator that other allergies may occur later. Literatures indicate that the molecular basis of patients with AD is different from that of healthy individuals. According to the classics of Traditional Chinese Medicine, the body constitution of patients with AD is also different. The purpose of this study is to determine the differences in pulse spectrum analysis between patients with AD and nonatopic healthy individuals.

METHODS

A total of 60 children (30 AD and 30 non-AD) were recruited for this study. A pulse spectrum analyzer (SKYLARK PDS-2000 Pulse Analysis System) was used to measure radial arterial pulse waves of subjects. Original data were then transformed to frequency spectrum by Fourier transformation. The relative strength of each harmonic wave was calculated. Moreover, the differences of harmonic values between patients with AD and non-atopic healthy individuals were compared and contrasted.

RESULTS

This study showed that harmonic values and harmonic percentage of C3 (Spleen Meridian, according to Wang's hypothesis) were significantly different.

CONCLUSIONS

These results demonstrate that C3 (Spleen Meridian) is a good index for the determination of atopic dermatitis. Furthermore, this study demonstrates that the pulse spectrum analyzer is a valuable auxiliary tool to distinguish a patient who has probable tendency to have AD and/or other allergic diseases.

Tuberculosis as a risk factor for systemic lupus erythematosus: results of a nationwide study in Taiwan

A previous study, with relatively small number of patients, showed that prior Mycobacterium tuberculosis (TB) may precipitate SLE in patients from endemic areas. The purpose of the study was to investigate the relationship between prior TB infection and systemic lupus erythematosus (SLE) from the National Health Insurance Research Database (NHIRD) in Taiwan. Cases of SLE and TB were identified from the NHIRD with corresponding ICD-9 codes 710.0 and 011-018, respectively, from January 2000 to December 2008. A total of 2,721 cases of SLE and 10,823 control subjects were included in data analysis. The average annual incidence rate was 8.1 per 100,000. The annual incidence rates of SLE decreased from 6.38 per 100,000 to 2.55 per 100,000 during 2000-2008. Compared with the control subjects, SLE patients were more likely to be white collar workers (P = 0.0005), reside in highly urbanized areas (P = 0.0140), and have higher incomes (P = 0.0088). TB was much more prevalent in SLE patients than in the control subjects (1.8 vs. 0.9%, P < 0.001). The mean time interval between diagnosis of TB and SLE was 45.58 ± 39.0 months. On multivariate analysis, TB was the greatest potential risk factor for precipitating SLE (OR = 2.11, 95% CI = 1.49-3.00). In addition, patients with co-existing TB and DM had a higher risk of SLE than the control group (OR = 3.91, 95% CI 1.84-8.31). In conclusion, this study suggests that there is an increased risk of precipitating SLE among patients with TB in Taiwan from a nationwide health insurance research dataset. Mycobacterial infections could trigger autoimmune diseases in experimental studies. Furthermore, a study with relatively small number of patients revealed that prior TB may precipitate SLE in patients from endemic areas. There is an increased risk of precipitating SLE among patients with TB in Taiwan from a nationwide health insurance research dataset during a 9-year period.

Clinical characteristics and outcomes of patients with obstructive sleep apnoea requiring intensive care

We reviewed the clinical characteristics, required intervention and short- and long-term outcomes in obstructive sleep apnoea (OSA) patients requiring intensive care. A retrospective, single-centre, observational cohort study was undertaken in a multidisciplinary teaching medical and surgical intensive care unit. Adult patients with OSA (apnoea-hypopnoea index of 5 or higher) requiring intensive care from January 2000 to January 2005 were included. Thirty-seven OSA patients (age: 58 +/- 14 years, male:female 27:10) were admitted due to respiratory (n=12, 32%), cerebrovascular (n=8, 22%), cardiovascular (n=16, 43%) and infectious events (n=1, 2.7%). Comparing the clinical features, polysomnographic data and outcome among these groups, we found that OSA patients admitted due to respiratory events had significantly higher Acute Physiology and Chronic Health Evaluation II scores, lower arterial blood gas pH, higher PaCO2, a higher incidence of respiratory failure (92%) and required non-invasive ventilation after extubation (73%), and higher intensive care unit readmission rates than patients admitted due to cerebrovascular events and cardiovascular events (P < 0.05). No difference was found in the in-hospital and long-term mortality rate. The most common reason for intensive care unit admission in critically ill OSA patients was a cardiovascular event, followed by respiratory and cerebrovascular events. The baseline polysomnographic data of the OSA patients were not correlated with their clinical features and outcomes in the intensive care unit. A more complicated clinical course and higher intensive care unit readmission rate were encountered in OSA patients admitted due to respiratory events. Further studies would be required to evaluate the efficacy of non-invasive ventilation for facilitation of extubation in OSA patients presenting with hypercapnic respiratory failure.

Ultrasound-guided pigtail catheters for drainage of various pleural diseases

OBJECTIVE

Little is known about the efficacy and safety of ultrasound-guided pigtail catheters for the management of various pleural diseases in the emergency department, ward, and intensive care unit.

METHODS

We conducted a retrospective study in a university hospital during a 1-year interval.

RESULTS

A total of 276 patients (178 men and 98 women) underwent 332 pigtail catheters (the drain size ranged from 10F to 16F) under ultrasound guidance. The mean ± SEM patient age was 59 ± 18 years, and mean duration of drainage was 6.1 ± 2 days. A total of 64 drains (19.2%) were inserted for pneumothoraces; 98 drains (29.5%), for malignant effusions; 119 drains (35.8%), for parapneumonic effusions/empyemas; and 38 drains (11.4%), for massive transudate pleural effusions. The overall success rate was 72.9%. The success rate was highest when the drain was used to treat massive transudate effusions (81.6%) and malignant pleural effusions (75.5%), followed by parapneumonic effusions/empyemas (72.2%), hemothoraces (66.6%), and pneumothoraces (64.0%). Only 10 (3.0%) drains had complications due to the procedure, including infection (n = 4, 1.2%), dislodgment (n = 4, 1.2%), wound bleeding at the pigtail catheter puncture area complicated with hemothoraces (n = 1, 0.3%), and lung puncture (n = 1, 0.3%). There was no significant difference in success rate when different catheter sizes were used to treat pleural diseases.

CONCLUSIONS

Ultrasound-guided pigtail catheters provide a safe and effective method of draining various pleural diseases. We strongly suggest that ultrasound-guided pigtail catheters be considered as the initial draining method for a variety of pleural diseases.

Systemic and bronchoalveolar cytokines as predictors of in-hospital mortality in severe community-acquired pneumonia

OBJECTIVES

The aim of this study was to determine whether cytokine expression (interleukin [IL]-1beta, IL-6, IL-8, IL-10, and tumor necrosis factor [TNF]-alpha), C-reactive protein, and endotoxins on the first day of intensive care unit (ICU) admission are associated with hospital mortality in severe community-acquired pneumonia (CAP).

DESIGN

This was a prospective study with bronchoalveolar lavage (BAL) and blood sampling.

SETTING

This study was carried out in a 44-bed medical ICU of a 1700-bed university hospital.

PATIENTS

Participants included 112 mechanically ventilated patients with severe CAP.

INTERVENTIONS

Serum and BAL fluid IL-1beta, IL-6, IL-8, IL-10, TNF-alpha, C-reactive protein, and endotoxins on the first day of ICU admission were obtained.

MEASUREMENTS AND MAIN RESULTS

The concentrations of TNF-alpha in BALF and IL-6, IL-8, IL-10, and TNF-alpha in serum were higher in nonsurvivors than in survivor patients with CAP. Of these 112 patients with severe CAP (39%), 44 developed acute respiratory distress syndrome (ARDS); these patients seemed to have higher serum IL-6, IL-8, and IL-10 levels than did the non-ARDS group. Furthermore, in the ARDS population, we found that the endotoxin levels in the BAL fluid were higher in the survival than in the nonsurvival group and BAL fluid concentrations of IL-6, IL-8, and IL-1beta and sera levels of IL-6 and IL-10 were lower in the survival than in the nonsurvival group, and they were associated with a high negative predictive value.

CONCLUSIONS

Serum and BAL fluid levels of the studied cytokines on admission may provide valuable prognostic information for patients with severe CAP.

Metallic stents for rescuing a patient with severe upper airway compression due to aortic aneurysm

Aortic aneurysm is usually a potentially life-threatening medical problem, with a 5-year survival rate of 20% if there is no surgical repair. Upper airway compression due to aortic aneurysm usually presents with wheezing, coughing, hemoptysis, dyspnea, or pneumonitis. We report a 78-year-old male patient with a history of chronic obstructive pulmonary disease who was admitted to our emergency department because of wheezing dyspnea for 2 days. Acute chronic obstructive pulmonary disease exacerbation with respiratory failure was impressed, but the patient had poor response to bronchodilators and systemic steroids treatment. Because chest radiography revealed a widening of the upper mediastinum and right lower lung collapse, fiberoptic bronchoscopy was performed and revealed narrowing at the lower portion of trachea and orifice of right main bronchus. Chest computed tomography scan showed aortic aneurysm involving the aortic arch and near the entire thoracic aorta. Because of his poor condition, surgery for aortic aneurysm was not suggested by the thoracic surgeons. We deployed expandable metallic stents in the right main stem bronchi and in the distal trachea. The patient was then weaned from mechanical ventilation a few days later.

Application of ultrasound-guided pigtail catheter for drainage of pleural effusions in the ICU

BACKGROUND

Little is known about the effectiveness of the pigtail catheter for drainage of pleural effusions in the intensive care unit (ICU).

METHODS

We conducted a retrospective review of adult patients (>/=18 years) who underwent ultrasound-guided pigtail catheter drainage of pleural effusions in the ICUs from January 2005 to July 2007 in a university hospital.

RESULTS

Among the 133 enrolled patients, there were 93 (70%) males and 40 (30%) females, with a mean age of 63.7 +/- 15.4 years old. The reasons for pigtail drainage were as follows: thoracic empyema (n = 59, 44%), massive transudative pleural effusions (n = 33, 25%), postoperative pleural effusion (n = 29, 15%), malignant pleural effusion (n = 18, 14%) and traumatic hemothorax (n = 3, 2%). In comparing the total amount of fluids drained, the duration of drainage, success rate and complication rate among these different causes of pleural effusion, pigtail drainage for massive transudative pleural effusion yielded the largest amount of pleural fluids (5,382 +/- 4,844 ml), provided the longest duration of drainage (9 +/- 7 days), and had the highest complication rate (18%). The success rate was highest when used to treat traumatic hemothorax (100%) and postoperative pleural effusions (85%); drains inserted for empyema were more likely to fail (overall success rate, 42%). No significant insertion complications, such as hollow organ perforation, were caused by this procedure.

CONCLUSION

The ultrasound-guided pigtail catheter inserted by intensivists is a well-tolerated and effective method of draining all kinds of pleural effusions in critically ill patients. We suggest that pigtail catheter drainage be considered as the initial treatment of choice in the ICU.

Sacral parasite conjoined twin

BACKGROUND

A variant of conjoined twins is one in which one twin is incomplete.

CASE

A female infant was born vaginally at 40 weeks' gestation to a healthy primipara. No important abnormalities were noted during prenatal examinations. The infant was fully developed in all external aspects except for a parasitic body conjoined with her sacrococcygeal region. Separated by operation 2 weeks after birth, the parasite contained lower limbs, adipose tissue, muscles, and a bowel sac. Over 4 years of observation, no abnormalities have been found since the operation.

CONCLUSION

Obstetricians should be aware of the existence of a parasite twin during prenatal examinations and of the importance of the differential diagnosis of parasite and teratoma, a neoplasm with malignant potential.

[Differentiation of natural killer cells into two functional subsets: NKh1 and NKh2]

OBJECTIVE

To verify the presence of functional subsets of natural killer cells based on the cytokine production.

METHODS

NK cells were purified and cultured in complete RPMI1640 medium in the presence of either IFN gamma + anti-IL-4(classical Th1 polarization) or IL-4 + anti-IFN gamma (classical Th2 polarization) for three days, and then were collected and detected for type I/type II cytokines by RT-PCR method.

RESULTS

NK cells were purified from 15 healthy donors, over 70% purity of NK cells were determined by flow cytometry. NK cells in peripheral blood expressed high level of type I cytokines, mainly IFN gamma, but low level of type II cytokines such as IL-10 and IL-13, IL-4 was not produced by NK cells. Cells cultured in IFN gamma + anti-IL-4 condition exhibited significantly increased level of IFN gamma, unchanged IL-2, and decreased type II cytokines. Cells grew in IL-4 + anti-IFN gamma condition exhibited increased IL-10 and IL-13, and decreased IFN gamma expressions.

CONCLUSIONS

Based on the cytokine production, NK cells may be divided into two functional subsets in the same manner as that of T lymphocytes(e.g. Th1/Th2): NKh1 and NKh2. The biological characterization and phenotypic marker are under investigate.

Promoter usage for insulin-like growth factor-II in cancerous and benign human breast, prostate, and bladder tissues, and confirmation of a 10th exon

Upregulation of insulin-like growth factor (IGF)-II expression has been reported for a variety of childhood and adulthood tumors. We determined IGF-II gene promoter usage in human cancerous and benign tissues by semiquantitative RT-PCR using P1-P4-specific primers. Although the human IGF-II gene structure is commonly thought to consist of nine exons and four promoters, we detected substantial utilization of a previously reported exon 4b, which is downstream of exon 4. Thus, exon 4b was intensively studied using 4b-specific primers. IGF-II gene promoter usage is highly variable in malignant and benign breast, prostate, and bladder tissues. While a majority of samples utilized P2-P4 promoters in a variety of combinations, when quantitated, P3 and P4 promoters were much more active than P2 promoter. This study not only demonstrated that IGF-II gene promoter usage is highly variable in malignant and benign tissues, but suggested that alternatively spliced exon 4b should be recognized as a 10th exon.

Cardiac type cGMP-inhibited phosphodiesterase (PDE3A) gene structure: similarity and difference to adipocyte type PDE3B gene

Phosphodiesterase type 3 isoforms, PDE3A and 3B, are expressed primarily in cardiovascular and adipose tissues, respectively. We previously reported a shorter transcript of 4.4-kb PDE3A which is predominantly transcribed in human placenta, whereas a full-length 7. 6-kb transcript corresponding to the cardiac PDE3A cDNA has not been characterized. Due to unfortunate circumstances created by changes in PDE3 nomenclature, PDE3B gene structure previously reported used PDE3A in its title. Here, we describe PDE3A gene structure, which comprises 16 exons spanning over 130 kb on chromosome 12p12. Two PDE3 isoforms share similar gene organization, but localize to different chromosomes. The most distal transcription initiation site of the PDE3A gene is approximately 1071 bases upstream of the ATG site, suggesting that exon 1 consists of 1071 and 960 bp of untranslated and translated sequences, respectively. The proximal 5'-flanking region, which does not contain TATA-like sequences, exhibited weak but significant promoter activity. Results suggest potential involvement of distal promoter/enhancer and translational regulation for expression of the 7.6-kb transcript.

[Experimental studies on changes in retinal enzyme activities under acute ocular hypertension in cat eyes]

The changes of 10 enzymatic activities of cat retinas and their blood vessels under acute ocular hypertension were systematically observed by enzyme histochemical methods. These changes were induced by the damage caused by retinal ischemia-reperfusion. The activities of the free radical scavengers, catalase and hydrogen peroxidase, were decreased, demonstrating that the excess of free radicals is one of the essential causes of the injury. The principles of treatment are besides lowering of intraocular hypertension, during retinal ischemic stage, oxygen and nutrients needed urgently should be supplied through extra-vascular route and during reperfusion stage, free radical scavengers ought to be given.

The role of COOH-terminal and acidic domains in the activity and stability of human insulin receptor protein tyrosine kinase studied by purified deletion mutants of the beta subunit domain

We have previously expressed the human insulin receptor beta subunit domain containing transmembrane and cytoplasmic domains (IRTMTPK) in insect cells, and showed that the purified IRTMTPK was highly active (Li, S. L., Yan, P.-F., Pax, I. B., and Fujita-Yamaguchi, Y. (1992) Biochemistry 31, 12455-12462). To investigate the role of COOH-terminal and acidic domains of the insulin receptor kinase, we have expressed deletion mutants IRTMTPK delta CT (delta 76 amino acids) and IRTMTPK delta Acid (delta 19 amino acids). Both enzymes were purified by a one-step method using the same immunoaffinity column as used for IRTMTPK. While Km and Vmax for prephosphorylated IRTMTPK and delta Acid mutant enzyme determined using poly(Glu, Tyr)(4:1) were similar, catalytic efficiency of the delta CT mutant enzyme was significantly lower than those of IRTMTPK and delta Acid mutant enzyme as judged by Km and Vmax. Experiments for thermostability and susceptibility to proteases revealed that Tm of delta CT mutant enzyme was 3.5 degrees C lower than that of IRTMTPK enzyme (= 33.3 degrees C) and that delta CT mutant enzyme was digested by either trypsin or Lys-C into a 28,000 core domain much faster than IRTMTPK. Activation of delta CT mutant enzyme by polylysine was less significant than that of IRTMTPK and delta Acid mutant enzyme, approximately 4-versus approximately 17-fold. These studies suggested that the COOH-terminal domain plays important roles in both catalytic efficiency and stability of the insulin receptor kinase, and that the acidic domain by itself is not responsible for kinase activation by polylysine.