Antibody blockade of Dectin-2 suppresses house dust mite-induced Th2 cytokine production in dendritic cell- and monocyte-depleted peripheral blood mononuclear cell co-cultures from asthma patients.

BACKGROUND: Dectin-2, which is a C-type lectin, interacts with the house dust mite (HDM) Dermatophagoides pteronyssinus allergen. This study aimed to investigate whether Dectin-2 blockade by antagonistic monoclonal antibodies (MoAbs) attenuates HDM-induced allergic responses. METHODS: Two anti-Dectin-2 MoAbs were generated and validated for specific binding to Dectin-2 Fc fusion protein (Dectin-2.Fc) and inhibition of Dectin-2.Fc/HDM interaction. Patients with asthma exhibiting high titers of anti-D. pteronyssinus IgE were enrolled. Peripheral blood mononuclear cells with depleted CD14+ monocytes were obtained from these patients and co-cultured with autologous monocyte-derived conventional dendritic cells in the presence of D. pteronyssinus or its group 2 allergens (Der p 2). Interleukin (IL)-5 and IL-13 levels in the culture supernatants were determined using ELISA in the presence or absence of anti-Dectin-2 MoAbs. RESULTS: Two MoAbs, 6A4G7 and 17A1D10, showed specific binding to recombinant Dectin-2.Fc and inhibited HDM binding to Dectin-2.Fc. Both anti-Dectin-2 MoAbs inhibited IL-5 and IL-13 production in co-cultures with Der p 2 stimulation in a dose-dependent manner. 6A4G7 and 17A1D10 (3 µg/mL) significantly inhibited Der p 2-induced (3 µg/mL) IL-5 production by 69.7 and 86.4% and IL-13 production by 84.0 and 81.4%, respectively. Moreover, this inhibitory effect of the two MoAbs remained significant in the presence of D. pteronyssinus. CONCLUSIONS: Anti-Dectin-2 MoAbs significantly inhibited HDM-induced allergic responses in vitro and therefore have the potential to become therapeutic agents in mite-induced allergic diseases.

Serum decoy receptor 3 is a biomarker for disease severity in nonatopic asthma patients.

BACKGROUND/PURPOSE: Decoy receptor 3 (DcR3), a soluble receptor of the tumor necrosis factor receptor superfamily, is a pleiotropic immunomodulator. The aim of this study was to investigate serum DcR3 levels in atopic and nonatopic asthma patients. METHODS: The serum DcR3 levels of 70 adults with asthma and 20 healthy controls were determined by enzyme-linked immunosorbent assay (ELISA). The asthma patients were divided into atopic and nonatopic subgroups, based on the presence or absence of immunoglobulin E (IgE) specific to allergen. Correlations between serum DcR3 levels and blood total-eosinophil counts, forced expiratory volume in 1 second (FEV1), FEV1/forced vital capacity (FVC), and Asthma Control Test (ACT) scores were analyzed. RESULTS: The mean serum DcR3 level was significantly higher in asthma patients than in healthy controls (266.1 ± 60.6 pg/mL vs. 63.7 ± 21.9 pg/mL, p = 0.003), but there was no significant difference between the mean serum DcR3 level of asthma patients with atopy (37 patients) and patients without atopy (33 patients; 298.7 ± 111.2 pg/mL vs. 230.6 ± 38.5 pg/mL, p = 0.064). However, the serum DcR3 level was positively correlated with the total eosinophil count (r = 0.448, p = 0.012) and inversely correlated with the percentages of predicted FEV1, FEV1/FVC, and ACT score (r = 0.409, p = 0.018; r = -0.399, p = 0.021; and r = -0.505, p = 0.003, respectively) in nonatopic asthma patients, but not in atopic patients. CONCLUSION: High serum DcR3 levels are associated with disease severity in nonatopic asthma patients, which suggests that DcR3 is a potential biomarker that can be used to predict the severity of nonatopic asthma.

Hyperbaric oxygen therapy as rescue therapy for pediatric frosted branch angiitis with Purtscher-like retinopathy: A case report.

Introduction: Frosted branch angiitis (FBA) is an uncommon uveitis characterized by fulminant retinal vasculitis. Purtscher-like retinopathy (PuR) is a rare retinal angiopathy associated with a non-traumatic etiology. Both FBA and PuR can cause profound visual impairments. Case report: We describe the case of a 10-year-old male who presented with sudden bilateral painless visual loss due to FBA with concurrent PuR, with notable viral prodrome 1 month prior to presentation. Systemic investigations revealed a recent herpes simplex virus 2 infection with a high titer of IgM, positive antinuclear antibody (ANA) (1:640), and abnormal liver function tests. After administration of systemic corticosteroids, anti-viral agents, and subsequent immunosuppressive medications, the FBA was gradually alleviated. However, fundoscopy and optical coherence tomography (OCT) revealed persistent PuR and macular ischemia. Hence, hyperbaric oxygen therapy was administered as a rescue strategy, which resulted in gradual bilateral visual acuity improvement. Conclusion: Hyperbaric oxygen therapy may be a beneficial rescue treatment for retinal ischemia secondary to FBA with PuR.

Comparisons of predictive performance of breathing pattern variability measured during T-piece, automatic tube compensation, and pressure support ventilation for weaning intensive care unit patients from mechanical ventilation.

OBJECTIVE: To investigate the influence of different ventilatory supports on the predictive performance of breathing pattern variability for extubation outcomes in intensive care unit patients. DESIGN AND SETTING: A prospective measurement of retrospectively analyzed breathing pattern variability in a medical center. PATIENTS: Sixty-eight consecutive and ready-for-weaning patients were divided into success (n=45) and failure (n=23) groups based on their extubation outcomes. MEASUREMENTS: Breath-to-breath analyses of peak inspiratory flow, total breath duration, tidal volume, and rapid shallow breathing index were performed for three 30-min periods while patients randomly received T-piece, 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure, and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure trials. Coefficient of variations and data dispersion (standard descriptor values SD1 and SD2 of the Poincaré plot) were analyzed to serve as breathing pattern variability indices. MAIN RESULTS: Under all three trials, breathing pattern variability in extubation failure patients was smaller than in extubation success patients. Compared to the T-piece trial, 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure decreased the ability of certain breathing pattern variability indices to discriminate extubation success from extubation failure. The areas under the receiver operating characteristic curve of these breathing pattern variability indices were: T-piece (0.73-0.87)>100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure (0.60-0.79)>5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure (0.53-0.76). Analysis of the classification and regression tree indicated that during the T-piece trial, a SD1 of peak inspiratory flow>3.36 L/min defined a group including all extubation success patients. Conversely, the combination of a SD1 of peak inspiratory flow ≤3.36 L/min and a coefficient of variations of rapid shallow breathing index ≤0.23 defined a group of all extubation failure patients. The decision strategies using SD1 of peak inspiratory flow and coefficient of variations of rapid shallow breathing index measured during 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure trials achieved a less clear separation of extubation failure from extubation success. CONCLUSIONS: Since 100% inspiratory automatic tube compensation with 5 cm H2O positive end-expiratory pressure and 5 cm H2O pressure support ventilation with 5 cm H2O positive end-expiratory pressure reduce the predictive performance of breathing pattern variability, breathing pattern variability measurement during the T-piece trial is the best choice for predicting extubation outcome in intensive care unit patients patients.

Degree of convexity calculated from expiratory flow-volume curves for identifying airway obstruction in nonsedated and nonparalyzed ventilated patients.

The predictive performance of applying the degree of convexity in expiratory flow-volume (EFV) curves to detect airway obstruction in ventilated patients has yet to be investigated. We enrolled 33 nonsedated and nonparalyzed mechanically ventilated patients and found that the degree of convexity had a significant negative correlation with FEV1% predicted. The mean degree of convexity in EFV curves in the chronic obstructive pulmonary disease (COPD) group (n = 18) was significantly higher than that in the non-COPD group (n = 15; 26.37 % ± 11.94 % vs. 17.24 % ± 10.98 %, p = 0.030) at a tidal volume of 12 mL/kg IBW. A degree of convexity in the EFV curve > 16.75 at a tidal volume of 12 mL/kg IBW effectively differentiated COPD from non-COPD (AUC = 0.700, sensitivity = 77.8 %, specificity = 53.3 %, p = 0.051). The degree of convexity calculated from EFV curves may help physicians to identify ventilated patients with airway obstruction.

Rapid shallow breathing index and its predictive accuracy measured under five different ventilatory strategies in the same patient group.

The rapid shallow breathing index (RSBI) is commonly used clinically for predicting the outcome of weaning from mechanical ventilation. We compared the RSBI and its predictive accuracies measured under 5 ventilatory strategies before weaning trials. Ninety-eight patients were included and divided into successful (n=71) and failed (n=27) groups based on their weaning outcomes. The RSBI was randomly measured when patients spontaneously breathed 21% O2 with no ventilator support (the control strategy) or were connected to ventilator breathing with 21% or 40% O2 and 0 or 5 cm H2O of continuous positive airway pressure (CPAP). We found that the RSBI values did not exhibit significant differences among the 4 ventilator strategies, but all were higher than that of the control; this remained valid in the non-chronic obstructive pulmonary disease (COPD) subgroup, but not in the COPD subgroup. Values of the area under the receiver operating characteristic curve of the RSBI for the 5 strategies were 0.51-0.62 with no significant difference between any 2 strategies. The incidences of adverse reactions (respiratory rate > or =35 breaths/min or oxygen saturation < or =89% for > or =1 min) were relatively high for the 21% O2-0 and 5 cm H2O CPAP groups (20 patients each) and low for the 40% O(2)-5 cmH2O CPAP group (2 patients). We concluded that RSBI values increased with the use of a ventilator, but not with additional applications of 40% 02 and/or 5 cm H2O CPAP. Their accuracies for predicting weaning outcome were unaltered by any of these interventions, but the incidence of adverse reactions increased with the use of the ventilator and decreased with additional 40% O2 supplementation.

Budesonide/Formoterol Anti-Inflammatory Reliever and Maintenance or Fluticasone Propionate/Salmeterol Plus As-Needed, Short-Acting ß2 Agonist: Real-World Effectiveness in pAtients without Optimally Controlled asThma (REACT) Study.

INTRODUCTION: In the prospective, observational, 16-week REACT study conducted between October 21, 2008 and May 12, 2011, we compared the real-world effectiveness of anti-inflammatory reliever and maintenance therapy with budesonide/formoterol (Symbicort® Turbuhaler) and maintenance therapy with fixed-dose fluticasone/salmeterol (Seretide®) plus as-needed, short-acting ß2 agonists (SABAs) in Taiwanese patients with inadequate asthma control. METHODS: Asthma control was assessed using the five-item Asthma Control Questionnaire (ACQ-5) and standardized pulmonary function testing. Assessments were performed at baseline and at weeks 4-5 and 12-16. Overall, we enrolled 842 patients at 11 clinics, 723 of whom were included in analyses (budesonide/formoterol, 563.3±1.3 µg/d, n=551; fluticasone/salmeterol, 1013.8±1.4 µg/d, n=172). RESULTS: At baseline, 72.5% and 27.5% of all patients had "partly" and "uncontrolled" asthma, respectively. Mean±SD ACQ-5 scores were 1.54±1.06 and 1.46±1.28 in the budesonide/formoterol and fluticasone/salmeterol groups, respectively. ACQ-5 scores significantly improved from baseline (ie, decreased) in both groups at weeks 4 and 16. ACQ-5 difference scores were significantly lower in the budesonide/formoterol group (-0.91±1.11) than the fluticasone/salmeterol group (-0.69±1.27) at the end of the study (p=0.027). Peak expiratory flow rate significantly improved from baseline in the budesonide/formoterol but not the fluticasone/salmeterol group at the end of the study. Severe exacerbation rates and medical resource utilization were comparable between the budesonide/formoterol and fluticasone/salmeterol groups. CONCLUSION: Collectively, results indicate the real-world effectiveness of budesonide/formoterol anti-inflammatory reliever and maintenance therapy is better than fixed-dose fluticasone/salmeterol plus as-needed SABA. TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT00784953.

Assessment of myocardial injury in the emergency department independently predicts the short-term poor outcome in patients with severe carbon monoxide poisoning receiving mechanical ventilation and hyperbaric oxygen therapy.

OBJECTIVES: Patients with severe carbon monoxide (CO) poisoning are often prone to unconsciousness and respiratory distress and as a result will receive mechanical ventilation and hyperbaric oxygen (MV-HBO) therapy. Factors associated with poor outcome at discharge are less defined in this patient population. This study was conducted to identify the prognostic predictors of short-term poor outcome in severely CO-poisoned patients receiving MV-HBO therapy. METHODS: The departmental database and the medical records of 81 patients treated with MV-HBO therapy were reviewed. Demographic and clinical data were extracted for analysis. HBO therapy with 2.5 or 2.8 atmosphere absolute (ATA) was administered to these patients. Short-term poor outcome was defined as an in-hospital death or neurologic sequelae at discharge. All patients were divided into two groups: those with a poor outcome and those without a poor outcome. RESULTS: Nine patients died while in the hospital, 32 patients had neurologic sequelae at discharge, and the incidence of poor outcome was 50.6%. Parameters that were assessed in the emergency department (ED) and highly associated with patients with a poor outcome included myocardial injury, typical findings on brain computed tomography related to CO poisoning, and higher serum levels of alanine transaminase, aspartate aminotransferase, blood urea nitrogen, creatinine, creatine kinase, creatine kinase-myocardial band, troponin-I, and C-reactive protein. These poor outcomes were also correlated with prolonged lag times from the end of CO exposure to ED arrival and from ED arrival to HBO therapy. In a multivariate analysis, myocardial injury was the only independent predictor of poor outcome (odds ratio, 8.2; 95% confidence interval, 1.012-67.610; p=0.049). CONCLUSIONS: The results of this study indicate that myocardial injury assessed at ED arrival independently predicts the short-term poor outcome in severely CO-poisoned patients who receive MV-HBO therapy. Emergency physicians could use this objective marker to identify patients with an increased risk of poor outcome at discharge and refine the treatment protocol by shortening the time of patient transport and administering HBO therapy as soon as possible.

Post-intensive care unit respiratory failure in older patients liberated from intensive care unit and ventilator: The predictive value of the National Early Warning Score on intensive care unit discharge.

AIM: The older adult population is continuously growing worldwide and there is increasing use of medical recourse in older patients, especially for those requiring intensive care unit (ICU) care and mechanical ventilation (MV). The present study aimed to investigate the burden and predictors of post-ICU respiratory failure in older ICU patients weaned from MV. METHODS: In the present retrospective study, older ICU patients aged ≥60 years, who were successfully weaned from MV and discharged to the general ward from the ICU of Taipei Veterans General Hospital, Taipei, Taiwan, in 2011, were included. Biomarkers on ICU discharge, as well as the National Early Warning Score (NEWS) were recorded and calculated. The outcome measure was post-ICU respiratory failure before day 14 (PIRF-14) requiring reinstitution of MV. Logistical regression was used to assess the predictors for PIRF-14. RESULTS: Of 272 patients included, 23 (8.5%) developed PIRF-14. The post-ICU in-hospital mortality rates were 47.8% and 6.8% in patients with and without PIRF-14 (adjusted OR 12.597, 95% CI 4.368-36.331). In a multivariate analysis, the levels of NEWS and hemoglobin on ICU discharge were independent predictors for PIRF-14 (adjusted OR 1.273, 95% CI 1.076-1.507 and 0.645, 95% CI 0.474-0.879). In particular, patients with a NEWS of ≥10 and subsequent PIRF-14 had a 15-fold increased risk of mortality as compared with those without both factors (adjusted OR 15.418, 95% CI 4.344-54.720). CONCLUSIONS: PIRF-14 is associated with high mortality in older ICU patients, and NEWS is a significant predictor for PIRF-14, which could be used to early identify patients at risk of post-ICU respiratory failure in the specific population. Geriatr Gerontol Int 2019; 19: 317-322.

Clinical assessment of propofol-induced yawning with heart rate variability: a pilot study.

STUDY OBJECTIVES: To investigate the proportion of propofol-induced yawning and sympathovagal balance during propofol-induced yawning. DESIGN: Prospective, observational, clinical study. SETTING: University hospital and 2400-bed tertiary medical center. PATIENTS: 546 ASA physical status I and II patients undergoing elective surgery with general anesthesia. INTERVENTIONS: Standard induction of anesthesia was performed with intravenous (IV) propofol two to four mg/kg (group P), or pretreatment with atropine 0.1 mg/kg (group AP) or with fentanyl 1 to 3 microg/kg (group FP) before propofol. Continuous standard electrocardiogram for heart rate variability (HRV) was performed in another 20 patients to investigate sympathovagal balance during propofol-induced yawning. MEASUREMENTS AND MAIN RESULTS: The proportions of yawning were 53.5% (207/386), 61.1% (55/90), and 0% (0/50) in the P, AP, and FP groups, respectively. Propofol-induced yawning could be dramatically decreased by pretreatment with IV fentanyl (P < 0.001, chi2 test). Significant increased ratio of low-frequency/high-frequency power was detected during HRV monitoring in 9 patients with yawning in comparison with 11 patients without yawning (P < 0.05, Wilcoxon signed-rank test). CONCLUSIONS: Pretreatment with fentanyl may inhibit propofol-induced yawning. Fluctuations in autonomic function have been noted during propofol-induced yawning.

Hyperbaric oxygen therapy for cesarean section wound in diabetes mellitus gravida.

We report the use of hyperbaric oxygen (HBO) therapy to treat the complication of necrotizing fasciitis following Cesarean section in a postpartum gravida with diabetes mellitus. Our patient was a 25-year-old, gravida 1, para 1, woman with a history of type 1 diabetes mellitus since the age of 18. The patient experienced preterm labor at 31+1 gestational weeks and was treated with magnesium sulfate for tocolytic therapy. The patient then went into labor at 39+6 gestational weeks. She received Cesarean section due to prolonged labor associated with non-reassuring fetal status of both smooth baseline and fetal tachycardia. An ultrasound scan of the lower abdomen on the 4th postoperative day revealed fluid collection measuring 4 mm over the rectus fascia and edematous change of the surrounding soft tissues under the Cesarean section incision site. The patient eventually received HBO for a total of 7 days. Following HBO, the condition of the surgical wound improved dramatically. The results of this case showed that HBO has the potential to be a cost-effective way to enhance the healing of necrotizing fasciitis in diabetes mellitus gravida.

Prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured SARS caring unit during outbreak: a prospective and periodic assessment study in Taiwan.

To assess the rapidly changing psychological status of nurses during the acute phase of the 2003 SARS outbreak, we conducted a prospective and periodic evaluation of psychiatric morbidity and psychological adaptation among nurses in SARS units and non-SARS units. Nurse participants were from two SARS units (regular SARS [N=44] and SARS ICU [N=26]) and two non-SARS units (Neurology [N=15] and CCU [N=17]). Participants periodically self-evaluated their depression, anxiety, post-traumatic stress symptoms, sleep disturbance, attitude towards SARS and family support. Results showed that depression (38.5% vs. 3.1%) and insomnia (37% vs. 9.7%) were, respectively, greater in the SARS unit nurses than the non-SARS unit nurses. No difference between these two groups was found in the prevalence of post-traumatic stress symptoms (33% vs. 18.7%), yet, three unit subjects (SARS ICU, SARS regular and Neurology) had significantly higher rate than those in CCU (29.7% vs. 11.8%, respectively) (p<0.05). For the SARS unit nurses, significant reduction in mood ratings, insomnia rate and perceived negative feelings as well as increasing knowledge and understanding of SARS at the end of the study (all p<0.001) indicated that a gradual psychological adaptation had occurred. The adjustment of nurses in the more structured SARS ICU environment, where nurses care for even more severely ill patients, may have been as good or better than that of nurses in the regular SARS unit. Occurrence of psychiatric symptoms was linked to direct exposure to SARS patient care, previous mood disorder history, younger age and perceived negative feelings. Positive coping attitude and strong social and family support may have protected against acute stress. In conclusion, the psychological impact on the caring staffs facing future bio-disaster will be minimized with lowered risk factors and a safer and more structured work environment.

Instability of spontaneous breathing patterns in patients with persistent vegetative state.

We investigated the breathing patterns of 27 patients in a persistent vegetative state (PVS) and 15 normal control volunteers. During the baseline period breathing air, 15 patients (the PVS-IB) exhibited irregular breathing (IB), whereas the other 12 (the PVS-OB) displayed oscillatory breathing (OB). Both groups maintained an average value for tidal volume (V(T)), total breath duration (T(TOT)), minute ventilation (V (E)), oxygen saturation (SpO2) similar to the control, but the PVS-OB displayed significantly lower end-tidal CO2 tension (P(ET)CO2) than the control. The V(T), T(TOT), V (E) and P(ET)CO2 of the PVS-OB showed cyclic changes. The coefficients of variation of V(T), T(TOT) and V (I) were: PVS-OB>PVS-IB>control. Inhalation of 100% O2 significantly reduced the respiratory variability and prevented OB of the PVS-OB. We concluded that PVS patients display respiratory instability and that brain damage, hypocapnia, and/or increased loop gain of arterial chemoreceptors may contribute to the pathogenesis of OB, whereas brain damage presumably may be the cause of IB.

Pneumothorax and mortality in the mechanically ventilated SARS patients: a prospective clinical study.

INTRODUCTION: Pneumothorax often complicates the management of mechanically ventilated severe acute respiratory syndrome (SARS) patients in the isolation intensive care unit (ICU). We sought to determine whether pneumothoraces are induced by high ventilatory pressure or volume and if they are associated with mortality in mechanically ventilated SARS patients. METHODS: We conducted a prospective, clinical study. Forty-one mechanically ventilated SARS patients were included in our study. All SARS patients were sedated and received mechanical ventilation in the isolation ICU. RESULTS: The mechanically ventilated SARS patients were divided into two groups either with or without pneumothorax. Their demographic data, clinical characteristics, ventilatory variables such as positive end-expiratory pressure, peak inspiratory pressure, mean airway pressure, tidal volume, tidal volume per kilogram, respiratory rate and minute ventilation and the accumulated mortality rate at 30 days after mechanical ventilation were analyzed. There were no statistically significant differences in the pressures and volumes between the two groups, and the mortality was also similar between the groups. However, patients developing pneumothorax during mechanical ventilation frequently expressed higher respiratory rates on admission, and a lower PaO2/FiO2 ratio and higher PaCO2 level during hospitalization compared with those without pneumothorax. CONCLUSION: In our study, the SARS patients who suffered pneumothorax presented as more tachypnic on admission, and more pronounced hypoxemic and hypercapnic during hospitalization. These variables signaled a deterioration in respiratory function and could be indicators of developing pneumothorax during mechanical ventilation in the SARS patients. Meanwhile, meticulous respiratory therapy and monitoring were mandatory in these patients.

Clinical features and outcomes of severe acute respiratory syndrome and predictive factors for acute respiratory distress syndrome.

BACKGROUND: Severe acute respiratory syndrome (SARS) is an emerging infectious disease, and indeed, the SARS epidemic in Taiwan from March to July 2003 had a great impact. This study depicts the clinical characteristics and short-term outcomes of patients with SARS treated at Taipei Veterans General Hospital; potential predictive factors for acute respiratory distress syndrome (ARDS) are also analyzed. METHODS: This study retrospectively analyzed data for 67 SARS patients, who were grouped according to whether or not ARDS developed during the clinical course of SARS. RESULTS: There were 32 males (mean age, 50.3 years; range, 20-75 years) and 35 females (mean age, 51.1 years; range, 23-86 years). Twenty-five patients (37.3%) were health care workers. At admission, 50 patients (74.6%) had abnormal chest radiographs, and all patients developed pulmonary infiltrates during the following week. During hospitalization, lymphopenia was found in 57 patients (85.1%); and elevated levels of lactate dehydrogenase (LDH; n = 55; 83.3%), C-reactive protein (n = 55; 83.3%), aminotransferases (n = 44; 65.7%), and creatine kinase (n = 14; 20.9%) were also noted. ARDS developed in 33 patients (49.3%), who were generally older than the patients in whom ARDS did not develop, male, non-health care workers, and who generally had dyspnea at the time of diagnosis, and a history of diabetes mellitus, hypertension or cerebrovascular accident. Patients with, versus those without, ARDS also tended to present with more severe lymphopenia and leukocytosis, and with higher levels of LDH and aspartate aminotransferase. The overall mortality rate was 31.3% (21/67), whereas the rate for patients who developed ARDS was 63.6% (21/33). Multivariate analyses showed that age greater than 65 years (odds ratio, OR, 10.6; 95% confidence interval, CI, 2.1-54.1), pre-existing diabetes mellitus (OR, 13.7; 95% CI, 1.3-146.9), and elevated levels of LDH (OR, 8.4; 95% CI, 1.9-36.9) at admission, were independent predictors of ARDS. CONCLUSION: The clinical manifestations of SARS showed high variability, and were related to the underlying health status of individual patients. Importantly, the development of ARDS was associated with significant mortality, despite aggressive therapy.

Synergistic impact of acute kidney injury and high level of cervical spinal cord injury on the weaning outcome of patients with acute traumatic cervical spinal cord injury.

INTRODUCTION: Respiratory neuromuscular impairment severity is known to predict weaning outcome among patients with cervical spinal cord injury; however, the impact of non-neuromuscular complications remains unexplored. This study was to evaluate possible neuromuscular and non-neuromuscular factors that may negatively impact weaning outcome. METHODS: From September 2002 to October 2012, acute traumatic cervical spinal cord injury patients who had received mechanical ventilation for >48h were enrolled and divided into successful (n=54) and unsuccessful weaning groups (n=19). Various neuromuscular, non-neuromuscular factors and events during the intensive care unit stay were extracted from medical charts and electronic medical records. Variables presenting with a significant difference (p<0.2) between these two groups were included in the univariate analysis. Following univariate analysis, those significantly different variables (p<0.05) were subjected to multivariate logistic regression to identify independent predictors of unsuccessful weaning. RESULTS: Compared to successful weaning patients, unsuccessful weaning patients were older; more often had high level of cervical spinal cord injury (C1-3), lower pulse rates, and lower Glasgow Coma Scale score on admission, higher peak blood urea nitrogen, lower trough albumin, and lower trough blood leukocyte counts. Furthermore, unsuccessful weaning patients had a higher incidence of pneumonia, acute respiratory distress syndrome, shock and acute kidney injury during the intensive care unit stay. Multivariate logistic regression analysis revealed acute kidney injury and high level of cervical spinal cord injury were independent risk factors for failure of weaning. Importantly, patients with both risk factors showed a large increase in odds ratio for unsuccessful weaning from mechanical ventilation (p<0.001). CONCLUSIONS: The presence of acute kidney injury during the intensive care unit stay and high level of cervical spinal injury are two independent risk factors that synergistically work together producing a negative impact on weaning outcome.

Breathing pattern variability: a weaning predictor in postoperative patients recovering from systemic inflammatory response syndrome.

OBJECTIVE: To investigate whether breathing pattern variability can serve as a potential weaning predictor for postoperative patients recovering from systemic inflammatory response syndrome (SIRS). DESIGN AND SETTING: A prospective measurement of retrospectively analyzed breathing pattern variability in a surgical intensive care unit. PATIENTS: Seventy-eight mechanically ventilated SIRS patients who had undergone abdominal surgery were included when they were ready for weaning. They were divided into success (n=57) and failure (n=21) groups based upon their weaning outcome. MEASUREMENTS AND RESULTS: Before weaning, tidal volume, total breath duration, inspiratory time, expiratory time, and peak inspiratory flow were continuously monitored for 30 min, while patients received 5 cmH2O pressure support weaning trial. After the patients successfully completed the trial, they were extubated. Successful weaning was defined as patients free from the ventilator for over 48 h, whereas a weaning failure was considered as reinstitution of mechanical ventilation within 48 h of extubation. The coefficient of variation and two values of standard deviation (SD1 and SD2; indicators of the dispersion of data points in the plot) obtained from the Poincaré plot of five respiratory parameters in the failure group were significantly lower than those in the success group. The area under the receiver operating characteristic curve of these variability indices was within the range of 0.73-0.80, indicating the accuracy of prediction. CONCLUSIONS: Small breathing pattern variability is associated with a high incidence of weaning failure in postoperative patients recovering from SIRS, and this variability may potentially serve as a weaning predictor.

Fentanyl-induced coughing and airway hyperresponsiveness.

BACKGROUND: The tussive effect of fentanyl, in sharp contrast to the antitussive effect that common opioids have, is not rarely seen in clinical anesthesia. Pretreatment with beta 2 agonist inhalation could dramatically suppress fentanyl-induced coughing. We hypothesized that airway hyperresponsiveness might exist in large proportion of the subjects who had experienced fentanyl-induced coughing during previous anesthesia. METHODS: We designed a case-controlled matching study to investigate the correlation between fentanyl-induced coughing and airway hyperresponsiveness. Twenty-six consecutive subjects (ASA I-III), who experienced fentanyl-induced coughing during anesthesia in our hospital from 1999 to 2000, were enrolled in this study as the fentanyl-cough group. In all the subjects baseline spirometry was first obtained. Airway responsiveness was evaluated with either PC20 of methacholine challenge test or bronchodilator test. After matching age and sex, another 26 subjects without history of fentanyl-induced coughing during previous anesthesia were also enrolled in the study as the control group. RESULTS: The proportion of airway hyperresponsiveness in fentanyl-cough group and control group was 30.77% and 19.23% respectively. After pairing of these two groups, McNemar test revealed no significant difference in the proportion of airway hyperresponsiveness between these two groups (P = 0.257). CONCLUSIONS: From the analysis of the present study, we cannot prove that there is a direct correlation between fentanyl-induced coughing and airway hyperresponsiveness.

Hyperbaric oxygen therapy as an effective adjunctive treatment for chronic Lyme disease.

Lyme disease is the most commonly reported vector-borne illness in the United States, but it is relatively rare in Taiwan. Lyme disease can be treated with antibiotic agents, but approximately 20% of these patients experience persistent or intermittent subjective symptoms, so-called chronic Lyme disease (CLD). The mechanisms of CLD remain unclear and the symptoms related to CLD are difficult to manage. Hyperbaric oxygen therapy (HBOT) was applied in CLD therapy in the 1990s. However, reported information regarding the effectiveness of HBOT for CLD is still limited. Here, we present a patient with CLD who was successfully treated with HBOT.

Intensive care unit-acquired bacteremia in mechanically ventilated patients: clinical features and outcomes.

Intensive care unit (ICU)-acquired bacteremia (IAB) is associated with high medical expenditure and mortality. Mechanically ventilated patients represent one third of all patients admitted to ICU, but the clinical features and outcomes in mechanically ventilated patients who develop IAB remain unknown. We conducted a 3-year retrospective observational cohort study, and 1,453 patients who received mechanical ventilation on ICU admission were enrolled. Among patients enrolled, 126 patients who had developed IAB ≧48 hours after ICU admission were identified. The study patients were divided into IAB and no IAB groups, and clinical characteristics of IAB based on specific bacterial species were further analyzed. The multivariate Cox regression analysis showed that ventilator support for chronic obstructive pulmonary disease and congestive heart failure, and patients admitted from nursing home were the independent risk factors for developing IAB. Patients with IAB were significantly associated with longer length of ICU stay, prolonged ventilator use, lower rate of successful weaning, and higher rate of ventilator dependence and ICU mortality as compared to those without IAB. IAB was the independent risk factor for ICU mortality (HR, 1.510, 95% CI 1.054-1.123; p = 0.010). The clinical characteristics of IAB related to specific bacterial species included IAB due to Pseudomonas aeruginosa being likely polymicrobial, lung source and prior antibiotic use; Escherichia coli developing earlier and from urinary tract source; methicillin-resistant Staphylococcus aureus related to central venous catheter and multiple sets of positive hemoculture; and Elizabethkingia meningoseptica significantly associated with delayed/inappropriate antibiotic treatment. In summary, IAB was significantly associated with poor patient outcomes in mechanically ventilated ICU patients. The clinical features related to IAB and clinical characteristics of IAB based on specific bacterial species identified in our study may be utilized to refine the management of IAB.