Risk of empyema in patients with chronic liver disease and cirrhosis: A nationwide, population-based cohort study.

BACKGROUND: Empyema is an important complication for patients with chronic liver disease and cirrhosis (CLDC). However, no study has investigated this relationship by using a population-based cohort study. METHODS: We used the National Health Insurance Research Data of Taiwan to identify a cohort of 76 027 CLDC patients newly diagnosed in 2000-2010 and a comparison cohort without CLDC of same size matched by age, gender and the year of diagnosis. The occurrence of empyema was monitored until the end of 2011. The hazard ratios (HRs) of empyema were estimated using the Cox model. RESULTS: The overall incidence of empyema was 66% greater in the CLDC group than in the non-CLDC group (3.85 vs 2.32/10 000 person-years, P<.001), with an adjusted HR of 1.54 (95% confidence interval [CI]=1.24-1.90). Compared with those without CLDC, adjusted HRs of empyema were 4.96 (95% CI=3.40-7.24) for patients with cirrhosis and 4.75 (95% CI=3.11-7.24) for patients with alcoholic CLDC. Further analyses revealed significant adjusted HRs of empyema among CLDC patients with ascites (5.76, 95% CI=4.13-8.04) and with gastrointestinal haemorrhage (1.60, 95% CI=1.03-2.48), compared to those without the respective disorders. Analyses using propensity score matched CLDC and non-CLDC cohorts revealed similar results. CONCLUSION: The present study shows that CLDC patients have an increased risk of empyema. These patients need timely monitor for the risk of empyema, particularly for those with comorbid cirrhosis, alcoholic disorder, gastrointestinal haemorrhage and ascites.

Risk of asthma in patients with primary Sjögren's syndrome: a retrospective cohort study.

BACKGROUND: Sjögren's syndrome (SS) has been associated with bronchial hyperresponsiveness and asthma; however, no population-based cohort study has been performed. We evaluated the risk of asthma in patients with primary SS in a nationwide population. METHODS: We conducted a retrospective cohort study using data from the National Health Insurance Research Database in Taiwan. The primary SS group included 4725 adult patients diagnosed between 2000 and 2006. Each patient was frequency-matched with four people without SS by sex, age and year of diagnosis. The occurrence and hazard ratio (HR) of asthma was monitored by the end of 2011. RESULTS: The overall incidence density of asthma was 1.62-fold higher in the primary SS group than in the non-SS group (9.86 vs. 6.10 per 1000 person-years), with a multivariable Cox proportional hazards model measured adjusted HR of 1.38 [95% confidence interval (CI) = 1.21-1.58]. Stratified analyses by sex, age group, and presence of comorbidity revealed that asthma incidences were all higher in the primary SS group than in the non-SS group, and the relative HRs of asthma associated with primary SS were significant in all subgroups. CONCLUSION: Patients with primary SS are associated with an increased risk of developing asthma. We should pay more attention to this group of individuals and provide them with appropriate support.

Lung cancer screening with low-dose computed tomography: Experiences from a tertiary hospital in Taiwan.

BACKGROUND/PURPOSE: Lung cancer screening using low-dose computed tomography (CT) has been reported to reduce lung cancer-specific mortality for smokers at high risk. However, despite different characteristics of lung cancer in Asia, there are few data concerning this specific population for screening. We aim to analyze the performance of lung cancer screening with low-dose CT concurrent with chest radiography in Taiwan, with reference to international experience. METHODS: During the 1-year period from January 2012 to December 2012, we conducted a retrospective, single-center population-based screening program for lung cancer in the setting of annual medical examinations. Participants were asymptomatic adults without prior history of any cancer. Low-dose CT and chest radiography were offered to all individuals. Baseline CT evaluations were defined as positive if any noncalcified nodule≥4 mm in diameter, which were then classified as solid, pure ground-glass or partial ground-glass opacity. RESULTS: Of 3339 individuals, we detected 34 cancers, yielding an overall cancer detection rate of 1.02%. There was a particularly high cancer detection rate of 6.2% (8/129) in the high-risk group aged younger than 50 years with a positive family history of all types of cancers in first-degree relatives. Adenocarcinomas accounted for 88% (30/34) of cancers and 99% of them were early-stage (including carcinoma in situ and Stage I). The probability of cancers was significant higher in nodules with interval growth (odds ratio 257.89, p = 0.0002). There was no significant difference in the probability of cancers between ground glass opacity nodules and solid nodules (odds ratio 1.16, p=0.72). Of all screen-detected cancers, 61.76% (21/34) were chest radiographically occult. CONCLUSION: Low-dose CT is effective to detect early lung cancers. Further establishment of selection criteria for lung cancer screening, specifically for Asian individuals, is definitely warranted.

Secondary spontaneous pneumothorax: which associated conditions benefit from pigtail catheter treatment?

OBJECTIVE: The study aimed to assess the clinical efficacy of pigtail catheter drainage for patients with a first episode of secondary spontaneous pneumothorax (SSP) and different associated conditions. METHODS: We retrospectively reviewed the records of patients with SSP who received pigtail catheter drainage as their initial management between July 2002 and October 2009. A total of 168 patients were included in the analysis; 144 (86%) males and 24 (14%) females with a mean age of 60.3 ± 18.3 years (range, 17-91 years). Data regarding demographic characteristics, pneumothorax size, complications, treatments, length of hospital stay, and associated conditions were analyzed. RESULTS: In total, 118 (70%) patients were successfully treated with pigtail catheter drainage, and 50 (30%) patients required further management. Chronic obstructive lung disease was the most common underlying disease (57% of cases). Secondary spontaneous pneumothorax associated with infectious diseases had a higher rate of treatment failure than SSP associated with obstructive lung conditions (19/38 [50%] successful vs 78/104 [75%] successful, P = .004) and malignancy (19/38 [50%] successful vs 13/16 [81%] successful, P = .021). Moreover, patients with SSP associated with infectious diseases had a longer length of hospital stay than those with obstructive lung conditions (23.8 vs 14.5 days, P = .003) and malignancy (23.8 vs 12.1 days, P = .017). No complications were associated with pigtail catheter drainage. CONCLUSIONS: A higher rate of treatment failure was noted in SSP patients with infectious diseases; thus, pigtail catheter drainage is appropriate as an initial management for patients with SSPs associated with obstructive lung conditions and malignancy.

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.

Outcome predictors of cirrhotic patients with spontaneous bacterial empyema.

BACKGROUND: Spontaneous bacterial empyema (SBE) is a complication of cirrhotic patients in which a pre-existing pleural effusion becomes infected. This retrospective study was designed to investigate the bacteriology and outcome predictors of SBE in cirrhotic patients. METHODS: Medical records of cirrhotic patients treated in a tertiary care university hospital from December 2004 to December 2008 were retrospectively reviewed. RESULTS: Of 3390 cirrhotic patients seen during the study period, 81 cases of SBE were diagnosed. The incidence of SBE was 2.4% (81/3390) in cirrhotic patients and 16% (81/508) in patients with cirrhosis with hydrothorax. There were 46 monomicrobial infections found in 46 SBE patients. Aerobic Gram-negative organisms were the predominant pathogens (n=29, 63%), and Escherichia coli (n=9, 20%) was the most frequently isolated sole pathogen. The mortality rate of SBE was 38% (31/81). Univariate analysis showed that Child-Pugh score, model for end-stage liver disease (MELD)-Na score, concomitant bacteraemia, concomitant spontaneous bacterial peritonitis, initial intensive care unit (ICU) admission and initial antibiotic treatment failure were predictors of poor outcomes. Multivariate regression analysis demonstrated that the independent factors related to a poor outcome were initial ICU admission [odds ratio (OR): 4.318; 95% confidence interval 1CI) 1.09-17.03; P=0.037], MELD-Na score (OR: 1.267; 95% CI 1.08-1.49; P=0.004) and initial antibiotic treatment failure (OR: 13.10; 95% CI 2.60-66.03). CONCLUSION: Spontaneous bacterial empyema in cirrhotic patients is a high mortality complication. The independent factors related to poor outcome are high MELD-Na score, initial ICU admission and initial antibiotic treatment failure. High MELD-Na score may be a useful mortality predictor of SBE in cirrhotic patients.

Panax notoginseng Attenuates Bleomycin-Induced Pulmonary Fibrosis in Mice.

Panax notoginseng (PN) is a traditional Chinese herb experimentally proven to have anti-inflammatory effects, and it is used clinically for the treatment of atherosclerosis, cerebral infarction, and cerebral ischemia. This study aimed to determine the anti-inflammatory effects of PN against bleomycin-induced pulmonary fibrosis in mice. First, in an in vitro study, culture media containing lipopolysaccharide (LPS) was used to stimulate macrophage cells (RAW 264.7 cell line). TNF-α and IL-6 levels were then determined before and after treatment with PN extract. In an animal model (C57BL/6 mice), a single dose of PN (0.5 mg/kg) was administered orally on Day 2 or Day 7 postbleomycin treatment. The results showed that TNF-α and IL-6 levels increased in the culture media of LPS-stimulated macrophage cells, and this effect was significantly inhibited in a concentration-dependent manner by PN extract. Histopathologic examination revealed that PN administered on Day 7 postbleomycin treatment significantly decreased inflammatory cell infiltrates, fibrosis scores, and TNF-α, TGF-ß, IL-1ß, and IL-6 levels in bronchoalveolar lavage fluid when compared with PN given on Day 2 postbleomycin treatment. These results suggest that PN administered in the early fibrotic stage can attenuate pulmonary fibrosis in an animal model of idiopathic pulmonary fibrosis.

The application of non-invasive and invasive mechanical ventilation in the first episode of acute respiratory failure.

Acute respiratory failure (RF) is a life-threatening syndrome. This study investigated the application of two major clinical strategies, non-invasive mechanical ventilation (NIV) and invasive mechanical ventilation (IMV), in the first episode of acute RF. Data from the longitudinal health insurance database, which included 1,000,000 insured citizens, were used. The NIV group consisted of 1201 patients and the IMV group consisted of 16,072 patients. Chi-square test and t test were applied to determine the differences in categorical and continuous variables. Further analysis was performed by using univariate and multivariable logistic regression and Poisson regression. There was a significant increase of 733% in the number of NIV users from 2000 to 2012. NIV use was frequently observed in old-age persons (aOR 3.99, 95% CI 3.06-5.21 for those aged ≥ 80 years), women (aOR 1.33, 95% CI 1.18-1.50), patients admitted to a high-level hospital (aOR 1.95, 95% CI 1.63-2.34 for those admitted to a medical center), and patients with a higher Charlson comorbidity index (CCI, aOR 1.38-1.66 for those CCI ≥ 2). In addition, patients with chronic pulmonary disease, cancer, and congestive heart failure were predominant in NIV users and were significantly associated with NIV use. Overall, the use of NIV has markedly increased over the past few years. Persons of advanced age, women, patients admitted to a high-level hospital, and patients with multiple comorbidities were associated with more frequent NIV use. Chronic pulmonary disease, cancer, and congestive heart failure were most important comorbidities for NIV use.

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.

Pigtail catheter for the management of pneumothorax in mechanically ventilated patients.

PURPOSE: There has been a paucity of data regarding the efficacy and safety of small-bore chest tubes (pigtail catheter) for the management of pneumothorax in mechanically ventilated patients. METHODS: We conducted a retrospective review of mechanically ventilated patients who underwent pigtail catheter drainage as their initial therapy for pneumothorax in the emergency department and intensive care unit from January 2004 through January 2007 in a university hospital. RESULTS: Among the 62 enrolled patients, there were 41 men (66%) and 21 women (34%), with a mean age of 63.8 +/- 20.3 years. A total of 70 episodes of pneumothoraces occurred in the intensive care unit, and 48 episodes of pneumothoraces (68.6%) were successfully treated with pigtail catheters. The average duration of pigtail drainage was 5.9 days (1-27 days). No major complications occurred through use of this procedure, except for pleural infections (n = 3, 4.2%) and clogged tube (n = 1, 1.4%). Comparing the variables between the success and failure of pigtail treatment, the failure group had a significantly higher proportion of Fio(2) >60% requirement (45.5% vs. 14.6%, P = .005) and higher positive end-expiratory pressure levels (8.7 +/- 3.0 vs. 6.2+/- 2.3 mm Hg, P = .001) at the time of pneumothorax onset than the success group. Further comparing the efficacy of pigtail drainage between barotraumas and iatrogenic pneumothorax, pigtail catheters for management of iatrogenic pneumothorax had a significantly higher success rate than barotraumas (87.5% vs. 43.3%, P < .0001). CONCLUSION: Pigtail catheter drainage is relatively effective in treating iatrogenic but less promising for barotraumatic pneumothoraces.

Effect of the Integrated Prospective Payment Program on Family Members' Knowledge and Acceptance of Hospice Care of Patients on Prolonged Mechanical Ventilation.

BACKGROUND: We sought to evaluate the effect of an integrated prospective payment program (IPP) on knowledge of hospice care and willingness to participate in hospice care among family members of patients on prolonged mechanical ventilation (PMV). METHODS: Between November 2013 and April 2014, we used paper-based survey questionnaires from 64 institutions to evaluate knowledge, willingness, and related factors among the main caregivers of patients on PMV regarding hospice care and to determine whether their decisions for the patients were affected by the IPP. RESULTS: The average ages of the respondents and patients on PMV were 51.9 y and 70.8 y respectively; 70.6% of the respondents knew about the Hospice Palliative Care Act (HPCA), and 42.3% of the medical staff had introduced hospice care-related information to patients and caregivers in Taiwan. Among the caregiver respondents, 67.6% agreed to write a letter of intent regarding the choice of hospice care or limited life-sustaining treatment. In total, 66.2% (16.1 + 50.1%) of the respondents agreed to hospice care for their family members (ie, the patients on PMV) when the condition was terminal. The factors of greater HPCA knowledge among the patients on PMV were IPP participation, female sex, and coma status. Factors leading to higher levels of HPCA knowledge included age ≥ 65 y being married, higher income, awareness of the law, and being introduced to hospice care by medical staff. CONCLUSIONS: High levels of hospice care knowledge were unrelated to willingness to participate. HPCA knowledge was greater in the IPP group than in the non-IPP group; however, there was no significant difference in the willingness to agree to hospice care. It is recommended that individuals be encouraged to express their medical decisions.

Hospital-acquired thoracic empyema in adults: a 5-year study.

BACKGROUND: The objective of this study was to assess the etiology, microbiology and outcome of hospital-acquired thoracic empyema (HATE) in adults. METHODS: From December 2001 to December 2006, 459 adult patients with a diagnosis of thoracic empyema in a tertiary hospital were screened for HATE. HATE was defined as a new pleural empyema which developed after 48 hours of hospitalization. RESULTS: In total, 56 adult (>or=18 years) patients who were diagnosed with HATE were enrolled in our series, including 35 men (62.5%) and 21 women (37.5%), with ages ranging from 22 to 87 years old (mean = 59). Causes of HATE were classified into two categories: hospital-acquired pneumonia (HAP) related (n = 25) and non-HAP related (n = 31). Causes of non-HAP related empyema were comprised of catheter-related infections (n = 20), hepatobiliary tract infections (n = 6), septic emboli (n = 4), and postpneumonectomy (n = 1). Comparing the bacteriology between the two categories, HAP-related empyema had a significantly higher incidence of aerobic Gram-negative organisms (76% vs. 38.7%, P = 0.005), polymicrobial pathogens (40% vs. 9.7%, P = 0.008), and anaerobic pathogens (20% vs. 0%, P = 0.009) than non-HAP related empyema. However, there was no significant difference in mortality rate (60% vs. 52%, P = 0.52) between the two categories. CONCLUSIONS: Choice of antibiotic treatment for HATE should be based on the etiology of the pleural infection. In treating HAP-related empyema, antibiotics should cover aerobic Gram-negative, polymicrobial, and anaerobic pathogens.

Correction: Risk of Obstructive Sleep Apnea in Adult Patients with Asthma: A Population-Based Cohort Study in Taiwan.

[This corrects the article DOI: 10.1371/journal.pone.0128461.].

Sonographic appearances in transudative pleural effusions: not always an anechoic pattern.

Pleural effusion patterns in sonographic appearances can be subclassified as anechoic, complex nonseptated, complex septated and homogeneously echogenic. Previous studies have suggested that transudates are usually anechoic; however, in daily practice we find frequently that heterogeneous echogenic material is present in transudative pleural effusions. This clinical study was to re-evaluate the sonographic appearances of transudative pleural effusions. A total of 127 patients with transudative pleural effusion that met Light's criteria ([1] a pleural fluid-serum protein ratio of <0.5, [2] a pleural fluid-serum lactate dehydrogenase [(LDH] ratio of <0.6 and [3] a pleural fluid LDH of less than two thirds of the upper limit of normal for serum LDH) and clinical presentations were enrolled. Results showed that transudative pleural effusions had the following sonographic appearances: an anechoic pattern in 45% (57/127) and a complex nonseptated pattern in 55% (70/127). There was no complex septated or homogenously echogenic pattern. In conclusion, sonographic presentations in transudative pleural effusions are not always in an anechoic pattern. If an afebrile patient without infectious symptoms/signs has bilateral pleural effusion compatible with transudate of Light's criteria, treat the underlying problems and ignore the complex nonseptated sonographic appearance. (E-mail: hsuwh@www.cmuh.org.tw).

Mortality in hepatitis C-positive patients treated with peritoneal dialysis.

OBJECTIVE: The published mortality data for patients with hepatitis C virus (HCV) infection and being treated with peritoneal dialysis (PD) are not available. The aim of this study was to determine the mortality of HCV patients undergoing PD. METHODS: We retrospectively reviewed 538 PD patients in our hospital from 1996 to 2005. Of these patients, 75 (13.9%) were anti-HCV positive at the beginning of PD. We used Kaplan-Meier analysis to compare mortality between patients with and patients without HCV infection. The association between HCV infection and mortality was analyzed using multivariate Cox regression with adjustment for age, gender, residual renal function, and cardiovascular disease. RESULTS: A total of 157 patients (39 HCV positive, 118 HCV negative) died during the 10-year follow-up period. The mortality rate (52%, 39/75) of HCV-positive patients was significantly higher than that of HCV-negative patients (25.5%, 118/463; p < 0.001). Cardiovascular mortality was 57.6% (68/118) among HCV-negative patients and 56.4% (22/39) among HCV-positive patients. Kaplan-Meier estimate showed that patients with HCV infection had higher mortality than those without (p < 0.001, log-rank). The result of Cox regression suggested that chronic HCV infection, independent of diabetes, was associated with 10-year mortality. The adjusted hazard ratios (HRs) of HCV infection and diabetes for mortality were 2.195 (95% CI: 1.486 - 3.243, p < 0.001) and 2.242 (95% CI: 1.533 - 3.277, p < 0.001). CONCLUSION: Our results show that the HCV-positive PD patients had a higher 10-year mortality rate than the HCV-negative PD patients. The association between HCV infection and mortality was independent of diabetes. Cardiovascular mortality, infection, and arrhythmia were the leading causes of death among the PD patients with HCV infection.

A 30-month experience of thoracic empyema in a tertiary hospital: emphasis on differing bacteriology and outcome between the medical intensive care unit (MICU) and medical ward.

OBJECTIVES: To analyze the causative pathogens and outcomes of patients with thoracic empyema admitted to the medical intensive care unit (MICU) and medical ward. METHODS: We prospectively studied the empyemic patients in the MICU and retrospectively analyzed the medical records of empyemic patients in the medical ward treated in a tertiary university hospital from April 2001 to September 2003. RESULTS: During this period, 116 patients in the medical ward and 78 patients in MICU had complicated parapneumonic effusions or empyemas. Effusion cultures were positive in 164 patients (85%); a total of 147 and 78 microorganisms were isolated from the 106 medical ward patients and 58 MICU patients, respectively. No matter whether medical ward or MICU patients, aerobic gram-negative organisms were the most common bacteria in positive-culture effusions (110, 67%). Klebsiella pneumoniae (14, 24%) was the predominant pathogen among the MICU patients, and Streptococcus spp. (28, 26%) was the main pathogen among the medical ward patients. Compared with these positive-culture empyemic patients in the medical ward, MICU patients had a significantly higher percentage of aerobic gram-negative organism infections (P = 0.034) and a higher infection-related mortality rate (P = 0.01). CONCLUSION: The mortality and predominant pathogens in patients with complicated parapneumonic effusions or thoracic empyemas in the medical ward and MICU were different. The increasing gram-negative pathogens in empyemas have become an urgent problem.

Risk of pleural empyema in patients with schizophrenia: a nationwide propensity-matched cohort study in Taiwan.

OBJECTIVE: Thoracic infection and pneumonia are prevalent in patients with schizophrenia; however, it is unclear whether patients with schizophrenia are at an increased risk of developing pleural empyema. DESIGN: A retrospective cohort study with propensity-matched cohorts with and without schizophrenia. SETTING: Using the National Health Insurance Research Database of Taiwan. PARTICIPANTS: We identified 55 888 patients with schizophrenia newly diagnosed in 2000-2011 and same number of individuals without schizophrenia as the comparison cohort, frequency matched by propensity scores estimated using age, sex, occupation, income, urbanisation, year of diagnosis and comorbidities. PRIMARY OUTCOME MEASURES: We assessed incident pleural empyema by the end of 2011 and used the Cox proportional hazards model to calculate the schizophrenia cohort to comparison cohort HR of pleural empyema. RESULTS: The overall incidence of pleural empyema was 2.44-fold greater in the schizophrenia cohort than in the comparison cohort (4.39vs1.80 per 10 000 person-years), with an adjusted HR of 2.87(95% CI 2.14 to 3.84). Stratified analyses by age, sex, occupation, income, urbanisation and comorbidity revealed significant hazards for pleural empyema associated with schizophrenia in all subgroups. CONCLUSIONS: Patients with schizophrenia are at an increased risk of developing pleural empyema and require greater attention and appropriate support.

Inactivation of hMLH1 and hMSH2 by promoter methylation in primary non-small cell lung tumors and matched sputum samples.

We performed a genetic and epigenetic study of the hMLH1 and hMSH2 mismatch repair genes in resected primary tumors from 77 non-small cell lung cancer (NSCLC) patients. The molecular alterations examined included the loss of mRNA and protein expression as well as promoter methylation, and the allelic imbalance of the chromosomal regions that harbor the genes. We found that 78% and 26% of patients showed at least one type of molecular alteration within the hMLH1 and hMSH2 genes, respectively. Promoter methylation of the hMLH1 gene was present in 55.8% of tumors, and was significantly associated with the reduction in mRNA and protein expression (P = 0.001). A 72% concordance of aberrant methylation in sputum samples with matched resected tumors was found. In addition, a 93% consistency between the promoter methylation and the mRNA expression of the hMSH2 gene was found in 14 female NSCLC patients. However, no correlation was found between the expression of hMLH1 and hMSH2 proteins and the allelic imbalance of five microsatellite markers closely linked to the genes. Our results suggest that hMLH1 is the major altered mismatch repair gene involved in NSCLC tumorigenesis, and that promoter methylation is the predominant mechanism in hMLH1 and hMSH2 deregulation. In addition, promoter methylation of the hMLH1 gene may be identified in sputum samples to serve as a potential diagnostic marker of NSCLC.

Different bacteriology and prognosis of thoracic empyemas between patients with chronic and end-stage renal disease.

BACKGROUND: Bacterial infections are a well-documented complication in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD). However, there are no previous studies of the empyemas that can develop in these patients. METHODS: This retrospective study investigated the bacteriology and outcomes of empyema in stage 4 CKD (predialysis) and ESRD patients receiving long-term dialysis and treated in a tertiary university hospital from January 2001 to March 2006. RESULTS: Eighty-four stage 4 CKD patients and 40 ESRD patients had empyemas. Most empyemas (n = 77, 62%) were secondary to pneumonia. Empyema culture findings were positive in 102 patients (82%): 87 microorganism were isolated in pleural fluid from 67 stage 4 CKD patients, and 39 microorganisms were isolated in pleural fluid from 35 ESRD patients. Aerobic Gram-negative organisms (n = 58, 67%), especially Klebsiella pneumoniae (n = 20, 34%), were the predominant pathogens in stage 4 CKD patients; aerobic Gram-positive organisms (n = 21, 54%), especially Staphylococcus aureus (n = 14, 67%), were the main pathogens in ESRD patients. Compared to stage 4 CKD patients, ESRD patients had a significantly higher percentage of catheter infections (p = 0.002) and aerobic Gram-positive organism bacteremia (p = 0.001), as well as a lower aerobic Gram-negative organism infection rate (p < 0.001) and a lower infection-related mortality rate (p = 0.022). CONCLUSION: Stage 4 CKD patients and ESRD patients with empyema have different causative pathogens and outcomes. In ESRD patients, the dialysis catheter or the dialysis process appear to alter the microbiological flora responsible for empyema. This finding has clinical implications that clinicians need to consider.