Predicting ventilator-associated pneumonia in elderly patients requiring mechanical ventilation through the detection in tracheal aspirates.

OBJECTIVE: In this study, we evaluated the clinical utility of tracheal aspirates α-amylase (AM), pepsin, and lipid-laden macrophage index (LLMI) in the early diagnosis of ventilator-associated pneumonia (VAP) in elderly patients on mechanical ventilation. METHODS: Within 96 hours of tracheal intubation, tracheal aspirate specimens were collected from elderly patients on mechanical ventilation; AM, pepsin, and LLMI were detected, and we analyzed the potential of each index individually and in combination in diagnosing VAP. RESULTS: Patients with VAP had significantly higher levels of AM, pepsin, and LLMI compared to those without VAP (P < 0.001), and there was a positive correlation between the number of pre-intubation risk factors of aspiration and the detection value of each index in patients with VAP (P < 0.001). The area under a receiver operating characteristic (ROC) curve (AUC) of AM, pepsin, and LLMI in diagnosis of VAP were 0.821 (95% CI:0.713-0.904), 0.802 (95% CI:0.693-0.892), and 0.621 (95% CI:0.583-0.824), the sensitivities were 0.8815, 0.7632, and 0.6973, the specificities were 0.8495, 0.8602, and 0.6291, and the cutoff values were 4,321.5 U/L, 126.61 ng/ml, and 173.5, respectively. The AUC for the combination of indexes in diagnosing VAP was 0.905 (95% CI:0.812-0.934), and the sensitivity and specificity were 0.9211 and 0.9332, respectively. In the tracheal aspirate specimens, the detection rate of AM ≥ cutoff was the highest, while it was the lowest for LLMI (P < 0.001). The detection rates of AM ≥ cutoff and pepsin ≥ cutoff were higher within 48 hours after intubation than within 48-96 hours after intubation (P < 0.001). In contrast, the detection rate of LLMI ≥ cutoff was higher within 48-96 hours after intubation than within 48 hours after intubation (P < 0.001). The risk factors for VAP identified using logistic multivariate analysis included pre-intubation aspiration risk factors (≥3), MDR bacteria growth in tracheal aspirates, and tracheal aspirate AM ≥ 4,321.5 U/L, pepsin ≥ 126.61 ng/ml, and LLMI ≥ 173.5. CONCLUSION: The detection of AM, pepsin, and LLMI in tracheal aspirates has promising clinical utility as an early warning biomarker of VAP in elderly patients undergoing mechanical ventilation.

Predictive value of α-amylase in tracheal aspirates for ventilator-associated pneumonia in elderly patients.

OBJECTIVE: This study aims to investigate the correlation between α-amylase in tracheal aspirates and risk factors of aspiration, as well as ventilator-associated pneumonia (VAP), in elderly patients undergoing mechanical ventilation and explore the clinical value of α-amylase for predicting VAP. METHODS: Tracheal aspirates were collected from elderly patients within 2 weeks after tracheal intubation in mechanical ventilation, and α-amylase was detected. Patients were grouped according to the presence of VAP. The correlation between α-amylase and risk factors of aspiration before intubation, as well as VAP, were analyzed. RESULTS: The sample of this study comprised 147 patients. The average age of these patients was 86.9 years. The incidence of VAP was 21% during the study period. Tracheal aspirate α-amylase level increased with the increase in the number of risk factors for aspiration before intubation, α-amylase level was significantly higher in the VAP group than in the non-VAP group, the area under the receiver operating characteristic curve (ROC) of the diagnostic value of α-amylase for VAP was 0.813 (95% CI: 0.721-0.896), threshold value was 4,681.5 U/L, sensitivity was 0.801 and specificity was 0.793. Logistic multivariate analysis revealed the following risk factors for VAP: a number of risk factors before intubation of ≥3, a Glasgow score of <8 points, the absence of continuous aspiration of subglottic secretion and a tracheal aspirate α-amylase level of >4681.5 U/L. CONCLUSION: Tracheal aspirate α-amylase can serve as a biomarker for predicting VAP in elderly patients undergoing mechanical ventilation.

[Clinical characteristics and risk factors affecting outcomes of elderly patients with non-small cell lung cancer complicated by chronic obstructive pulmonary disease].

OBJECTIVE: To investigate the clinical features, treatment strategy and risk factors affecting the prognosis of elderly patients with non-small cell lung cancer (NSCLC) complicated by chronic obstructive pulmonary disease (COPD). METHODS: We retrospectively analyzed the data of elderly patietns (>60 years) with newly diagnosed NSCLC complicated by COPD at the Geriatric Institution of General Hospital of PLA between January, 2000 and June, 2015. The clinical data collected included history of smoking, pulmonary function test results, initial treatments, TNM stage, chief complaints, comorbidities and laboratory tests. The Cox proportional hazards regression model was used to explore the prognostic factors in these patients. RESULTS: A total of 200 NSCLC patients were reviewed, of which 107 (53.5%) patients had the co-morbidity of COPD as confirmed by spirometry using bronchodilator test. The median survival of the patients with NSCLC complicated by COPD was 45.8 months with 1-, 3-, 5-, and 10-year survival rates of 80.4%, 55.4%, 41.0% and 20.0%, respectively. Stratification analysis showed that patients with COPD Gold grades 1 and 2 had a significant longer median overall survival (51.7 and 43.1 months, respectively) than those with grade 3/4 (16.9 months; P=0.020 and 0.043, respectively). Univariate and multivariate analyses using Cox proportional hazards regression model showed that an older age, a higher Gold grade, advanced disease stage (stages III and IV), squamous cell carcinoma, nonsurgical initial treatment, coughing and an elevated serum CEA level were independent risk factors for shorter survival of the patients. CONCLUSION: Multiple prognostic factors can affect the outcomes of elderly patients with NSCLC complicated by COPD, and a higher COPD Gold grade that fails to respond to treatment within 3 months is the independent risk factor for survival of the patients.

A propensity-matched analysis of surgery and stereotactic body radiotherapy for early stage non-small cell lung cancer in the elderly.

Elderly patients with early stage non-small cell lung cancer (NSCLC) who undergo surgical resection are at a high risk of treatment-related complications. Stereotactic body radiation therapy (SBRT) is considered an alternative treatment option with a favorable safety profile. Given that prospective comparative data on SBRT and surgical treatments are limited, we compared the 2 treatments for early stage NSCLC in the elderly.We retrospectively collected information from the database at our geriatric institution on patients with clinical stage IA/B NSCLC who were treated with surgery or SBRT. The patients were matched using a propensity score based on gender, age, T stage, tumor location, pulmonary function (forced expiratory volume in 1 second [FEV1]% and FEV1), Charlson comorbidity score, and World Health Organization performance score. We compared locoregional control rate, recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS) between the 2 treatment cohorts before and after propensity score matching.A total of 106 patients underwent surgery, and 74 received SBRT. Surgical patients were significantly younger (72.6 ±â€Š7.9 vs 82.6 ±â€Š4.1 years, P = 0.000), with a significantly higher rate of adenocarcinoma (P = 0.000), better Eastern Cooperative Oncology Group performance scores (P = 0.039), and better pulmonary function test results (P = 0.034 for predicted FEV1 and P = 0.032 for FEV1). In an unmatched comparison, there were significant differences in locoregional control (P = 0.0012) and RFS (P < 0.001). The 5-year OS was 69% in patients who underwent surgery and 44.6% in patients who underwent SBRT (P = 0.0007). The 5-year CSS was 73.9% in the surgery group and 57.5% in the SBRT group (P = 0.0029). Thirty-five inoperable or marginally operable surgical patients and 35 patients who underwent SBRT were matched to their outcomes in a blinded manner (1:1 ratio, caliper distance = 0.25). In this matched comparison, the follow-up period of this subgroup ranged from 4.2 to 138.1 months, with a median of 58.7 months. Surgery was associated with significantly better locoregional control (P = 0.0191) and RFS (P = 0.0178), whereas no significant differences were found in OS (5-year OS, 67.8% for surgery vs 47.4% for SBRT, P = 0.07) or CSS (67.8% for surgery vs 58.2% for SBRT, P = 0.1816).This retrospective analysis found superior locoregional control rates and RFS after surgery compared with SBRT, but there were no differences in OS or CSS. SBRT is an alternative treatment option to surgery in elderly NSCLC patients who cannot tolerate surgical resection because of medical comorbidities. Our findings support the need to compare the 2 treatments in randomized controlled trials.

[Gene Diagnosis and Analysis of Clinical Hematological Phenotype of Thailand Deleted α-Thalassemia 1].

OBJECTIVE: To investigate the hematologic characteristics and gene diagnosis of patients with Thailand deleted α-thalassemia 1, so as to provide the information for clinical genetic counseling. METHODS: The clinical data of 32 patients with Thailand delated α-thalassemia 1 were analyzed retrospectively; the hematologic characteristics and gene diagnosis of Thailand deleted type were investigated by using routine hematologic examination, genetic detection of common thalassemia and Thailand deleted α-thalassemia 1. RESULTS: Among 32 cases, the Thailand deleted α-thalassemia 1 heterozygote was found in 29 cases, the Thailand deleted α-thalassemia 1 and α(3.7) gene deletion double heterozygote were found in 1 case, the Thailand deleted α-thalassemia 1 with ß-thalassemia (1 case with codons 41-42 mutation heterozygous, 1 case with CD17 mutation heterozygous) was found in 2 cases by detection. The MCV and MCH levels were decreased in all cases of Thailand deleted thalassemia 1, there were significant differences in RBC, MCV, MCH (P<0.05) between normal control and Thailand deletion α-thalassemia 1 group; there were also significant differences in MCHC (P<0.05) between Southeast asia thalassemia and Thailand deleted α-thalassemia 1 group. CONCLUSION: There are no significant differences in hematological parameters except MCHC between Southeast asia thalassemia and Thailand deleted α-thalassemia 1 group. moreover the Thailand deleted α-thalassemia 1 in a certain proportion exists in area with high incidence of thalassemia, therefor the clinicians should pay more attention to the screen and diagnosis of Thailand delated α-thalassemia and can exactly diagnose the Thailand delected α-thalassemia 1 on the basis of comprehensive analysis of conventional and Thailand delected α-thalassemia 1 detection results, clinical presentation, hematologic parameters and ultrasonic examination, so as to avoid the birth of child with severe and intermidiate type α-thalassemia caused by Thailand deleted α-thalassemia 1.

Heme oxygenase-1 system, inflammation and ventilator-induced lung injury.

Mechanical ventilation is an indispensable supportive intervention for acute respiratory failure. However, mechanical ventilation can provoke ventilator-induced lung injury, which remains one of the major causes of morbidity and mortality in critically ill patients. Excessive inflammatory response characterized by infiltration of inflammatory cells and overproduction of inflammatory mediators contributes to the pathogenesis of ventilator-induced lung injury. At present, apart from the protective ventilation strategy, no other pharmacological intervention is available to attenuate ventilator-induced lung injury. Heme oxygenase-1 (HO-1) is the inducible isoform of the first and rate-limiting enzyme which degrades heme into carbon monoxide, ferritin and bilirubin. Accumulating evidence suggests that HO-1 system may function as a crucial negative regulator in the modulation of inflammatory process. This anti-inflammatory action of HO-1 is mediated essentially by the regulation of the key cells involved in inflammation and restoration of the balance between pro-inflammatory and anti-inflammatory mediators. Therefore, HO-1 system represents a promising therapeutic target for intervention of ventilator-induced lung injury.

[Geriatric respiratory medicine: a field needs be furthered strengthened].

Respiratory diseases are common in the elderly and often the main causes of death among this population. In addition, it is expected that chronic obstructive pulmonary disease, lower respiratory tract infections, lung cancer, and pulmonary tuberculosis will be listed in the top ten diseases in 2020. Therefore, screening, diagnosis and management of respiratory diseases should be strengthened among the elderly; meanwhile, studies on geriatric respiratory medicine should be further enhanced.

[Enterococcus faecium lung abscess: one case report and literature review].

OBJECTIVE: to study the diagnosis and treatment of enterococcus faecium lung abscess. METHODS: a retrospective analysis of one case of Enterococcus faecium lung abscess and literature review was conducted. RESULTS: this patient suffered from cough and sputum over 6 months and complicated with hemoptysis over 3 months. Pulmonary embolism and lung cancer were suspected initially. After 2 times of CT-guided percutaneous transthoracic needle aspiration biopsy the diagnosis of pneumonia was made in other hospitals. However, the consolidation in the lung progressed and cavity appeared although antibiotic therapy was conducted. After admission to our hospital, CT-guided percutaneous transthoracic needle aspiration biopsy was made and the lung tissue was sent for bacterial culture. Enterococcus faecium was cultured and it was susceptible to vancomycin, teicoplanin and linezolid. The disease improved significantly after treatment with these 3 antibiotics in turn. In addition, 13 cases of enterococcus pneumonia or lung abscess were reviewed, including 3 cases of enterococcus faecium lung abscess. CONCLUSIONS: enterococcus faecium is rarely a pathogen for lung abscess. The diagnosis of enterococcus faecium lung abscess could be confirmed by lung biopsy and bacterial culture of lung tissue which could also provide the susceptibility of antibiotics and guide the antibiotic therapy.

[The establishment of a rat model of chronic pulmonary infection due to Pseudomonas aeruginosa].

OBJECTIVE: To establish a rat model of chronic pulmonary infection by inoculating two different Pseudomonas aeruginosa embedded in minute seaweed alginate beads made by an ejection set with an acuminata hole to Sprague-Dawley rats. To evaluate the animal model with bacteriology and pathology values. METHOD: (1) 300 healthy, clean Sprague-Dawley rats were divided into 3 groups randomly: the wide-type Pseudomonas aeruginosa group (PAO(1) group), the mutant type Pseudomonas aeruginosa group (PAO-JP2 group) and the control group. (2) Two different Pseudomonas aeruginosa were embedded in minute seaweed alginate beads by an ejection set with an acuminata hole. Then the beads were inoculated into the rats' lung through tracheal intubation. The bacteria numbers in lung and pathology scores were measured 3, 7, 14, 28 days after infection. RESULTS: (1) The bacteriology values: No bacterium were detected in the control group. PAO(1) and PAO-JP2 were detected from rats of PAO1 and PAO-JP2 infected groups respectively. Bacterial number was higher than 10(5) CFU/g 3, 7 days after infection (LgCFU/g): 3 d: PAO1 group: 19 +/- 6, PAO-JP2 group: 17 +/- 7; 7 d: PAO1 group: 13 +/- 4, PAO-JP2 group: 12 +/- 4) and higher than 10(3) CFU/g 14, 28 days after infection (LgCFU/g: 14 d: PAO1 group: 11.3 +/- 2.8, PAO-JP2 group: 9.6 +/- 3.3; 28 d: PAO1 group: 9.1 +/- 1.5, PAO-JP2 group: 4.2 +/- 3.0). (2) The pathological changes showed: 3, 7 days after infection, lung abscess, edema, consolidation, haemorrhage can be seen from lungs of both groups. And at optical microscopic, alginate-Pseudomonas aeruginosa caused a pronounced inflammatory reaction with polymorphonuclear cells surrounding a bead. Small microcolonies formed at the periphery of the bead were also seen. 14, 28 days after infection, the consolidation reduced gradually and lung atelectasis, fibrinous adhesions and granulomas became the major pathological changes, which is more significant in the PAO(1) group. CONCLUSION: The animal model of chronic pulmonary infection can be established by inoculating Pseudomonas aeruginosa embedded in minute seaweed alginate beads made by an ejection set with an acuminata hole to Sprague-Dawley rats.

[The role of the quorum sensing system in a rat model of Pseudomonas aeruginosa pulmonary infection and its relationship with the expression of virulence factors].

OBJECTIVE: A variety of in vitro experiments indicated that most of the extracellular virulence factors of Pseudomonas aeruginosa (PA) were controlled by the quorum sensing system. The aim of this study was to explore the role of the quorum sensing system in a rat model of PA pulmonary infection. METHODS: Rats were infected intratracheally with PA strain PAO1 or PAO1-JP2 (lasI rhlI double mutant) which was embedded in seaweed alginate bead. The difference of bacteriology and pathology between the two groups was compared. The in vitro activity of elastase was measured by the Congo Red method and the expression of exotoxin A was detected by Western blot. RESULTS: At the 14th and 28th days after challenge, the bacterial colony counts in the PAO1-JP2 group were (9.6 +/- 3.3) lgCFU/g and (4.2 +/- 3.1) lgCFU/g respectively; however, those of the PAO1 group were (11.3 +/- 2.8) lgCFU/g and (9.1 +/- 1.5) lgCFU/g respectively, which showed significant difference (P < 0.05). The lung index of macroscopic pathology (LIMP) and the score of macroscopic pathology of the PAO1-JP2 group were significantly lower than those of the PAO1 group at 7th, 14th and 28th days after challenge. The size of lung abscesses or granuloma in the lung under the microscope and the score of microscopic pathology of the PAO1-JP2 group were also significantly lower at the 7th, 14th and 28th days. The in vitro activity of elastase of the PAO1-JP2 strain was 0.02 +/- 0.00 and that of the PAO1 strain was 0.35 +/- 0.03, which showed significant difference (P < 0.05). The expression of exotoxin A could be detected by Western blot in the PAO1 strain but not in the PAO1-JP2 strain. CONCLUSION: When the quorum sensing system of PA was deficient the expression of some virulence factors, such as elastase and exotoxin A, were decreased, which resulted in milder pulmonary infection.

[Comparison of lung function measurement values with two different apparatus].

This paper introduces a random measurement analysis of, lung function measurement values with two different apparatus. in 41 patients. It shows that the differences are not statistically significant (P>0.05) between two apparatus measurement values except DLCO, FEF25, FEF75 in the group of normal ventilation, FVC in the group of abnormal ventilation. The two groups are both correlated closely (r> 0.9) except MMF(r=0.7725, RV r=0.808) in the normal group of ventilation, and FEF75 (r=0.58) in the abnormal group of ventilation (p<0.001). The two apparatus with different measuring theories have a good correlation.

[The quantitative detection of anti-coronavirus antibody titer in medical personnel closely contacted with severe acute respiratory syndrome patients].

OBJECTIVE: To study the serum anti-coronavirus antibody titer in medical personnel who had closely contacted with severe acute respiratory syndrome (SARS) patients. METHODS: The serum anti-coronavirus IgG antibody titer in medical personnel who had closely contacted with SARS patients, healthy individuals, patients with community acquired pneumonia and patients recovered from SARS was detected by using an enzyme-linked immunosorbent assay (ELISA) method. The antibody titer was expressed as the value of absorbency (A) with common logarithm conversion. RESULTS: The serum anti-coronavirus IgG antibody titer in patients recovered from SARS was 0.07 +/- 0.13, which was significantly higher as compared with those in other groups. The antibody titer in medical personnel was -1.18 +/- 0.20, which was also significantly higher as compared with those in community acquired pneumonia patients and healthy persons. In the healthy persons, the antibody titer of serum samples obtained from Beijing in May, 2003 was -1.61 +/- 0.13, which was significantly higher than that of samples obtained from Beijing in 2001 when SARS was not found -1.76 +/- 0.25 and that of samples from Shandong province where SARS was not found in May, 2003 -1.95 +/- 0.44. There was no significant difference in the antibody titer between patients of bacterial pneumonia and patients of atypical pneumonia, which was -1.99 +/- 0.31 and -2.05 +/- 0.23 respectively. CONCLUSION: Close contact with SARS patients can cause the serum anti-coronavirus antibody titer to increase significantly in medical personnel, a phenomenon deserves further study.