Therapeutic hypothermia application vs standard support care in post resuscitated out-of-hospital cardiac arrest patients.

INTRODUCTION: Survival after cardiac arrest remains poor, especially when it occurs outside of hospital. In recent years, therapeutic hypothermia has been used to improve outcomes in patients who have experienced cardiac arrest, however, application to out-of-hospital cardiac arrest (OHCA) patients remains controversial. METHODS: A total of 175 OHCA patients underwent therapeutic hypothermia (TH), which was performed using large volume ice crystalloid fluid (LVICF) infusions after ICU admission. Ice packs and conventional cooling blankets were used to maintain a core body temperature of 33°C, according to standard protocol for 36 hours. Patients in the control group received standard supportive care without TH. Hospital survival and neurologic outcomes were compared. RESULTS: There was no significant difference between the groups with regards to patient characteristics, underlying etiologies, and length of hospital stays. The duration of cardiac pulmonary resuscitation (CPR) was also similar. In the 51 patients that received TH, 14 were alive at hospital discharge. In the 124 patients belonging to the supportive care group, only 15 were alive at hospital discharge (27.5% vs. 12.1%, p = 0.013). Approximately 7.9% of patients in the TH group had good neurologic outcomes (4 of 51) compared with the 1.7% (2 of 124) of patients in the supportive group (p = 0.04). There were no specific treatment-related complications. CONCLUSION: Therapeutic hypothermia can be safely applied to OHCA patients and can improve their outcome. Further large scale studies are needed to verify our results.

Effect of a hospital-based case management approach on treatment outcome of patients with tuberculosis.

BACKGROUND/PURPOSE: Tuberculosis (TB) continues to pose a heavy public health burden in Taiwan. This prospective study analyzed the factors influencing treatment outcome in patients with TB treated with and without a hospital-based case management (HBCM) approach in a referral center in Taipei. METHODS: A register-based cohort study design was used to enroll all new cases of pulmonary or extrapulmonary TB from February 2003 to January 2004. The case manager served as the coordinator among patients, physicians and public health nurses, to facilitate compliance with anti-TB treatment. Treatment outcomes were assessed according to the consensus recommendations of the World Health Organization and the International Union Against Tuberculosis and Lung Disease. RESULTS: Suspected or confirmed pulmonary or extrapulmonary TB was diagnosed in 524 patients in our hospital from February 2003 to January 2004. Fifty-two of these patients were excluded due to duplicate reporting, previous treatment or death before enrollment. Out of 472 patients enrolled, 103 whose original diagnosis was revised were further excluded, leaving 369 cases eligible for analysis. Patients with case management had a significantly higher rate of successful treatment (cured plus completed treatment) compared to patients without case management, (240/277, 86.6% vs. 67/92, 72.8%; p = 0.002). The overall successful treatment rate including both case and non-case management was 83.2% (307/369), which was higher than the nationwide surveillance data of 78.3% in 2002 and 69.4% in 2003. CONCLUSION: Treatment of TB patients by a HBCM approach provides improved treatment outcomes compared to those without case management.

Agenesis of right upper lobe of lung.

Agenesis of the right upper lobe of the lung is a very uncommon congenital anomaly and may be referred to chest clinics in adulthood for an incidental finding of abnormal chest radiograph. The presentations of chest radiograph may imitate many common situations such as right upper lobe collapse presenting as an ipsilateral shifting of the mediastinum or elevation of the right hemidiaphragm due to eventration or subdiaphragmatic lesions. A chest computed tomography is considered the most conclusive examination used to diagnose lung agenesis. Three-dimensional reconstructed images can be particularly helpful in delineating abnormalities of the bronchi and associated arterial and venous structures. We describe here a young woman with allergic rhinitis and bronchial asthma since her early childhood. She was referred to our clinic for an incidental finding of abnormal chest radiograph after a school health checkup. Right upper lobe atelectasis or intra-abdominal lesions were initially suspected. After a thorough image study, she was diagnosed as a case of agenesis of the right upper lobe. Our report emphasizes the importance that a high index of suspicion and adequate image investigation are necessary to diagnose congenital lung anomalies.

Clinical and laboratory features of severe acute respiratory syndrome vis-a-vis onset of fever.

STUDY OBJECTIVES: Severe acute respiratory syndrome (SARS) is a rapidly progressive disease caused by a novel coronavirus (CoV) infection. However, the disease presentation is nonspecific. The aim of this study was to define clearly the presentation, clinical progression, and laboratory data in a group of patients who had SARS. DESIGN: Retrospective observational study. SETTING: A tertiary care medical center with 51 negative-pressure isolation rooms in Taipei, Taiwan. PATIENTS: Fifty-three patients with SARS seen between April 27 and June 16, 2003. RESULTS: Fever (ie, temperature > 38 degrees C) was the most common symptom (98%) and the earliest. When admitted to the isolation unit of the hospital for observation, most patients reported nonspecific symptoms associated with their fever. Only two patients with preexisting illnesses had cough on the same day the fever began. Eventually, 39 patients (74%) developed cough, beginning at a mean (+/- SD) time of 4.5 +/- 1.9 days after fever onset, and 35 patients (66%) had diarrhea beginning at a mean time of 6.0 +/- 3.3 days after fever onset. Thirty-one patients (59%) had abnormal findings on chest radiographs on hospital admission, and all but 1 patient (98%) eventually developed lung infiltrates that were consistent with pneumonia. The majority of patients (63%) first developed unifocal infiltrates at a mean time of 4.5 +/- 2.1 days after fever onset, while in 37% of patients the initial infiltrates were multifocal, appearing at a mean time of 5.8 +/- 1.3 days after fever onset. Common laboratory findings included lymphopenia (on hospital admission, 70%; during hospitalization, 95%), thrombocytopenia (on hospital admission, 28%; during hospitalization, 40%), elevated lactate dehydrogenase (on hospital admission, 58%; during hospitalization, 88%), creatine kinase (on hospital admission, 18%; during hospitalization, 32%), and aspartate aminotransferase or alanine aminotransferase levels (on hospital admission, 27%; during hospitalization, 62%). Throat or nasopharyngeal swab for SARS-CoV by reverse transcriptase polymerase chain reaction (PCR) and real-time PCR was positive in 40 of the 47 patients (85%) in whom the test was performed. CONCLUSIONS: None of the presenting symptoms or laboratory findings are pathognomonic for SARS. Even though cough developed in a majority of patients, it did not occur until later in the disease course, suggesting that a cough preceding or concurrent with the onset of fever is less likely to indicate SARS. While PCR for SARS-CoV appears to be the best early diagnostic test currently available, it is clear that better methods are needed to differentiate between SARS and non-SARS illness on initial presentation.

Inflammatory myofibroblastic tumor mimicking anterior mediastinal malignancy.

Inflammatory myofibroblastic tumor arising in the anterior mediastinum is rare. A 58-year-old woman had an anterior mediastinal mass invading the sternum, pericardium, and pleura. It was completely resected and found to be an inflammatory myofibroblastic tumor. The patient was well and had no recurrence 6 months after surgery.