Isolated respiratory tract microorganisms and clinical characteristics in asthma exacerbation of obese patients: a multicenter study.

BACKGROUND: Viral infection is a risk factor for asthma exacerbation (AE). However, bacterial infections related to AE in adults are poorly known. On the other hand, obese patients with asthma have their own clinical and biological characteristics compared with non-obese patients. METHODS: We investigated the differences in isolated pathogens for AE between obese and non-obese patients with asthma. We included 407 patients with AE from 24 medical centers in Korea. Microorganisms isolated from culture, RT-PCR or serologic tests using lower respiratory tract specimens were retrospectively investigated. RESULTS: A total of 171 obese and 236 non-obese patients with asthma were included for analysis. Compared to non-obese patients, obese patients were associated with women (77.2% vs. 63.6%), never smoker (82.5% vs. 73.9%), shorter duration of asthma (7.9 ± 8.4 vs. 10.5 ± 10.1 years), less history of pulmonary tuberculosis (8.8% vs. 17.4%), and more comorbidity of allergic rhinitis (48.5% vs. 0.8%). Viral and/or bacterial infections were detected in 205 patients (50.4%) with AE. The numbers of patients with viral only, bacterial only, or both infections were 119, 49, and 37, respectively. The most commonly isolated bacterium was Streptococcus pneumoniae, followed by Pseudomonas aeruginosa and Chlamydia pneumoniae. Obese patients showed a lower incidence of Chlamydia pneumoniae infection. In the non-obese group, bacterial infection, especially Chlamydia pneumoniae infection, was significantly associated with the duration of systemic corticosteroid use (13.6 ± 19.8 vs. 9.7 ± 6.7 days, p = 0.049). CONCLUSION: Bacterial infection was associated with a longer period of corticosteroid use in the non-obese group. Acute Chlamydia pneumoniae infection was less associated with obese patients with AE. Further well-designed studies are needed to evaluate microorganisms and the efficacy of antibiotics in patients with AE.

A novel FLCN gene mutation causing Birt-Hogg-Dubé syndrome in a Korean family.

Spontaneous pneumothorax is a common manifestation of Birt-Hogg-Dubé (BHD) syndrome, an inherited disorder caused by mutation of the folliculin (FLCN) gene. A 44-year-old female with a history of breast cancer was diagnosed with recurrent pneumothorax. Chest CT showed multiple cysts with left lung pneumothorax, and she received surgery for the diagnosis. Because the patient also had a family history of spontaneous pneumothorax, a FLCN genetic examination was conducted. A novel heterozygous, likely pathogenic variant (NM_144997.5:c.779+2T > C) was detected in the proband, her mother, and aunt. This is the first report of a new mutation of FLCN gene in a BHD syndrome patient.

Impact of COPD Treatment on Survival in Patients with Advanced Non-Small Cell Lung Cancer.

Chronic obstructive pulmonary disease (COPD) is associated with a poor prognosis in patients with non-small cell lung cancer (NSCLC). However, the impact of COPD treatment on the survival of patients with advanced NSCLC remains uncertain. We retrospectively investigated COPD patients among patients newly diagnosed with advanced NSCLC between September 2005 and August 2019 at a university hospital. The clinical characteristics, lung function, and survival outcomes were analyzed and compared between patients who did and did not receive COPD treatment. Among 221 patients with advanced NSCLC and COPD, 124 patients received treatment for COPD and 97 patients did not receive treatment for COPD. Forced expiratory volume in 1 s (FEV1) % predicted value was greater in the no-treatment group than in the COPD treatment group (p < 0.001). The median overall survival (OS) of the treatment group was 10.7 months, while that of the no-treatment group was 8.7 months (p = 0.007). In the multivariate analysis, COPD treatment was independently associated with improved OS (hazard ratio 0.71, 95% confidence interval 0.53−0.95, and p = 0.021). COPD treatment was associated with improved OS in patients with advanced NSCLC and COPD. Therefore, pretreatment spirometry and maximal treatment for COPD may offer a chance of optimal management for patients with advanced NSCLC.

Clinical characteristics and outcomes among older nursing home residents hospitalized with pneumonia.

BACKGROUND: Due to population aging, the number of cases of pneumonia in nursing homes in South Korea has been increasing. This study investigated the characteristics and clinical outcomes in nursing home residents with pneumonia admitted to a tertiary hospital. METHODS: A retrospective cohort study was conducted of patients transferred to the tertiary hospital from nursing homes between August 2009 and October 2016. The in-hospital mortality, Pneumonia Severity Index, bacterial pathogens in sputum cultures, and antibiotic sensitivity profile were assessed. RESULTS: The analysis included a total of 174 patients hospitalized with pneumonia. Their median age was 78 years, and 109 patients (62.6%) were male. 108 patients (62.1%) were admitted to the intensive care unit. The in-hospital mortality rate was 12.6% (22/174). Culture of a multidrug-resistant (MDR) pathogen was an independent risk factor for mortality (odds ratio [OR]: 3.72, 95% confidence interval [CI]: 1.16-11.89). Male sex and a history of antibiotic use within the previous 3 months were independent risk factors for MDR pathogen isolation (OR: 3.32, 95% CI, 1.38-7.98 and OR: 3.93, 95% CI: 1.82-8.49, respectively). CONCLUSIONS: Detection of an MDR pathogen, rather than host factors such as old age, bedridden status, and comorbidities, was the most important risk factor for in-hospital mortality in patients with nursing home pneumonia. Patients with a history of antibiotic use within the previous 3 months had a higher probability of MDR pathogen identification. Identifying MDR pathogens is important in treating older nursing home residents with pneumonia.

Comparison of epidermal growth factor receptor tyrosine kinase inhibitors for patients with lung adenocarcinoma harboring different epidermal growth factor receptor mutation types.

BACKGROUND: Epidermal growth factor receptor (EGFR) mutations in non-small-cell lung cancer predict sensitivity to EGFR tyrosine kinase inhibitors (TKIs). EGFR mutation types are associated with efficacy of EGFR TKIs. We investigated the clinical outcomes of afatinib, erlotinib, and gefitinib according to EGFR mutation type in patients with lung adenocarcinoma. METHODS: Between May 2010 and December 2018, we investigated 363 patients with advanced lung adenocarcinoma harboring EGFR mutations who received EGFR TKIs. Efficacies of EGFR TKIs such as response rate, progression-free survival (PFS), and overall survival (OS) were retrospectively evaluated according to exon 19 deletion (E19del), L858R point mutation (L858R) and uncommon mutations. RESULTS: The frequency of E19del was 48.2%, that of L858R was 42.4%, and that of uncommon mutations was 9.4%. E19del and L858R were associated with superior PFS and OS compared with uncommon mutations. Erlotinib showed significantly inferior OS than other TKIs (30.8 ± 3.3 in erlotinib vs. 39.1 ± 4.3 in afatinib vs. 48.4 ± 6.3 in gefitinib; p = 0.031) in patients with L858R. Gefitinib showed significantly inferior PFS (4.6 ± 1.1 in gefitinib vs. 11.6 ± 2.7 in afatinib vs. 10.6 ± 2.7 in erlotinib; p = 0.049) in patients with uncommon mutations. CONCLUSION: Afatinib was significantly associated with a longer PFS, presenting constant effectiveness in all EGFR mutation types. Caution may be needed on the use of erlotinib for L858R and the use of gefitinib for uncommon EGFR mutations.

Impact of right ventricular systolic pressure in elderly patients admitted to intensive care unit after femur fracture surgery: A retrospective observational study.

The number of femoral fractures is expected to continue to increase as the size of the older population rapidly grows. However, old age is accompanied by various comorbidities and is an important postoperative risk factor in itself, meaning that patients who undergo surgery for a femur fracture may require admission to an ICU. We investigated pulmonary complications in patients over the age of 65 admitted to the ICU after femur fracture surgery.In this single-center retrospective observational study, 289 patients over 65 years who admitted to the ICU after femur fracture surgery between June 2008 and December 2016 were investigated.Pulmonary complications occurred in 97 of these patients (33.6%) after surgery. Mean hospitalization days (34.1 ±â€Š25.7 vs 23.1 ±â€Š15.7, P < .001) and mean ICU length of stay (8.4 ±â€Š16.1 vs 2.5 ±â€Š1.1, P = .001) were significantly longer for patients with pulmonary complications than for patients without pulmonary complications after femur fracture surgery. Patients with pulmonary complications were significantly more likely to have pulmonary disease (19.6% vs 8.9%, P = .009) and exhibit sequelae on preoperative chest X-rays (9.3% vs 3.6%, P = .048) than were patients without pulmonary complications. In addition, significant differences were observed in the right ventricular systolic pressure (RVSP) measured during preoperative echocardiography (37.4 ±â€Š10.9 mm Hg vs 40.7 ±â€Š9.3 mm Hg for patients without and with pulmonary complications, P = .010) and in the proportion of each group that had an RVSP of >35 mm Hg, which is a marker for pulmonary hypertension (55.2% vs 76.3% for patients without and with pulmonary complications, P < .001). In multivariate analysis, an RVSP of >35 mm Hg during preoperative echocardiography was associated with pulmonary complications after femur fracture surgery (OR, 2.6; 95% CI, 1.45-4.53).In conclusion, Pulmonary complications in older patients admitted to the ICU after femur fracture surgery was associated with longer hospitalization and ICU stays. Preoperative RVSP measurement could identify those older patients with a high risk of pulmonary complications following transferal to the ICU after femur fracture surgery.

Diagnostic yield of additional conventional transbronchial lung biopsy following radial endobronchial ultrasound lung biopsy for peripheral pulmonary lesions.

BACKGROUND: Radial endobronchial ultrasound (R-EBUS) transbronchial lung biopsy (TBLB) improves the diagnostic yield from peripheral pulmonary lesions (PPLs). However, the small specimens obtained using small forceps through a guide sheath (GS) may impede diagnosis and molecular analysis. Here, we investigated the diagnostic significance of additional conventional TBLB with standard forceps after R-EBUS-GS-guided TBLB. METHODS: We retrospectively reviewed data from 55 patients who underwent conventional TBLB after R-EBUS-GS-guided TBLB for PPL diagnosis. Procedures were performed on single PPLs with no visible lesions on bronchoscopy. In cases with inconclusive pathologic confirmation, final diagnoses were made based on pathologic specimens or clinical observations. RESULTS: The median size of the target lesions was 28 mm. The appearances on computed tomography images were solid (n = 45, 81.8%), part-solid (n = 7, 12.7%), and cavitary nodules (n = 3, 5.5%). A computed tomography bronchus sign was present in 35 (63.6%) cases, and a radial probe was positioned within target lesion in 32 (58.2%) cases. R-EBUS-GS-guided TBLB was diagnostic in 30 (54.5%) patients, and subsequent conventional TBLB yielded additional diagnostic information in 8 (14.5%) patients. Probe positioning within target lesions and the outer margin of PPLs more than 1 cm from pleura were significantly associated with enhanced diagnostic yield from the combined procedures. In conventional TBLB, probe positioning within target lesions (75.0% vs. 11.8%, P = 0.004) and characteristic of nonsolid nodules (83.3% vs. 15.8%, P = 0.006) were significantly associated with additional diagnostic utility. CONCLUSIONS: Conventional TBLB following R-EBUS-GS-guided TBLB could be a useful procedure for diagnosing PPLs, especially for nonsolid nodules. KEY POINTS: Significant findings of the study: Additional conventional TBLB with standard forceps after R-EBUS-GS-guided TBLB yielded an additional 14.5% diagnostic utility for peripheral pulmonary lesions. For conventional TBLB, probe positioning within target lesions and nonsolid nodules were significantly associated with additional diagnostic utility. WHAT THIS STUDY ADDS: Conventional TBLB with standard forceps after R-EBUS-GS-guided TBLB is an effective and economically accessible diagnostic tool for peripheral pulmonary lesions.

Clinical significance of EGFR mutation types in lung adenocarcinoma: A multi-centre Korean study.

Adenocarcinoma is the most common type of non-small cell lung cancer. Some causative genomic alterations in epidermal growth factor receptor (EGFR), including deletions in exon 19 (E19 dels) and a point mutation in E21, are known to have favourable prognoses due to sensitivity to tyrosine kinase inhibitors; however, the prognoses of other uncommon mutations are unclear. This study analysed the clinical significance of EGFR mutation types in lung adenocarcinoma. We retrospectively reviewed 1,020 subjects (mean age: 66.8 years, female: 41.7%) who were diagnosed with advanced lung adenocarcinoma, had EGFR mutation data, and did not undergo surgery from five medical institutes between 2010 and 2016. Subjects were classified according to EGFR mutation status, particularly for exon-specific mutations. EGFR positivity was defined as the presence of mutation and EGFR negativity was defined as wild-type EGFR. EGFR positivity was 38.0%, with the incidence of mutations in E18, E19, E20, and E21 was 3.6%, 51.0%, 3.4%, and 42.0%, respectively. The EGFR positive group survived significantly longer than the negative group (p<0.001), and there was a significant difference in survival among the four EGFR mutation sites (p = 0.003); E19 dels were the only significant factor that lowered mortality (HR: 0.678, p = 0.002), while an E21 mutation was the prognostic factor associated with the most increased mortality (HR: 1.365, p = 0.015). Amongst EGFR positive subjects, the proportion of E19 dels in TKI-responders was significantly higher and that of E21 mutations significantly lower, compared with non-responders. In TKI treatment, mutations in E18 and E20 were not worse factors than the E21 L858R mutation. In conclusion, the presence of EGFR mutations in advanced lung adenocarcinoma can predict a good prognosis; E19 dels prospect to have a better prognosis than other mutations, while an E21 mutation is expected to increase mortality.

Clinical features and outcomes in patients with pulmonary complications during pregnancy and peripartum.

Introduction: The aim of this study was to investigate clinical features and identify maternal factors contributing to prognosis in women with pulmonary complications during pregnancy and the peripartum period.Materials and methods: Following a retrospective review of clinical data and radiographic findings between January 2006 and January 2016, 126 women diagnosed with pulmonary complications during pregnancy (N = 79) and peripartum within the first 4 weeks after delivery (N = 47) were enrolled in this study.Results: Of the 126 patients, 113 (89.7%) required hospitalization. The median age was 32 years, and the percentage of primiparous women was 49.2%. The most common respiratory complaint was dyspnea, followed by cough and fever. Pneumonia developed in 50 patients (39.6%), pulmonary edema in 31 (24.6%), pleural effusion in 28 (22.2%), active pulmonary tuberculosis in 13 (10.3%), and asthma exacerbation in 4 (3.1%). Among the 79 antenatal patients with pulmonary complications, 31 (39.2%) experienced pregnancy-related complications, 21 (26.6%) had an emergency C-section, and 29 (36.7%) had an adverse fetal outcome. Eleven patients (8.7%) developed acute respiratory failure requiring mechanical ventilation, and the overall mortality was 1.6% (2/126) with no pulmonary complication-related deaths. Multiple regression analysis revealed that presence of pregnancy-related complications and younger fetal gestational age at the diagnosis were independent predictive factors for adverse fetal outcomes.Discussion: Pulmonary complications during pregnancy and the peripartum period resulted in poor outcomes, and the risk of adverse fetal outcomes was high, particularly in patients with pregnancy-related complications and younger gestational age at the diagnosis.

Risk factors associated with an increase in the size of ground-glass lung nodules on chest computed tomography.

BACKGROUND: The detection rate of ground-glass nodules (GGNs) in the lung has increased with the increased use of low-dose computed tomography (CT) of the chest for cancer screening; however, limited data is available on the natural history, follow-up, and treatment of GGNs. The aim of this study was to identify factors associated with an increase in the size of GGNs. METHODS: A total of 338 patients (mean ages, 59.8 years; males, 35.5%) with 689 nodules who underwent chest CT at our institute between June 2004 and February 2014 were included in this study. The cut-off date of follow-up was August 2018. We analyzed the size, solidity, number, and margins of the nodules compared with their appearance on previous chest CT images. The Cox proportional hazard model was used to identify risk factors associated with nodule growth. RESULTS: The median follow-up period was 21.8 months. Of the 338 patients, 38.5% had a history of malignancy, including lung cancer (8.9%). Among the 689 nodules, the median size of the lesions was 6.0 mm (IQR, 5-8 mm), and the proportion of nodules with size ≥10 mm and multiplicity was 17.1% and 66.3%, respectively. Compared to the nodules without an increase in size, the 79 nodules with an increase in size during the follow-up period were initially larger (growth group, 7.0 mm vs. non-growth group, 6.0 mm; P = 0.027), more likely to have a size ≥10 mm (26.6% vs. 15.9%; P = 0.018), and had less frequent multiplicity (54.4% vs. 67.9%, P = 0.028). In the multivariate analysis, nodule size ≥10 mm (hazard ratio [HR], 2.044; P = 0.005), a patient history of lung cancer (HR: 2.190, P = 0.006), and solitary nodule (HR: 2.499, P < 0.001) were independent risk factors for nodule growth. CONCLUSION: Careful follow-up of GGNs is warranted in patients with a history of malignancy, a large , or a solitary nodule.

Hemoptysis requiring bronchial artery embolization in patients with nontuberculous mycobacterial lung disease.

BACKGROUND: Although infections caused by nontuberculous mycobacteria (NTM) are increasing in prevalence, there are few data about hemoptysis in patients with NTM lung disease. This study investigated the characteristics and prognosis of hemoptysis secondary to NTM infection. METHODS: Following a retrospective review of cases managed between 2006 and 2016, 183 patients with NTM lung disease were enrolled and analyzed. RESULTS: Among 183 patients with NTM lung disease, Mycobacterium intracellulare (n = 64, 35%) was the major cause of NTM infection, followed by M. avium (n = 59, 32.2%) and M. abscessus complex (n = 40, 21.9%). Hemoptysis developed in 78 patients (42.6%), among whom 33 (42.3%) required bronchial artery embolization (BAE). Between patients with and without hemoptysis, there were no significant differences with respect to sex, radiographic manifestations, distribution over 3 lobes on chest computed tomography, history of pulmonary tuberculosis, antiplatelet or anticoagulation therapy, and species of NTM. However, mean age at diagnosis was significantly lower in the hemoptysis group in univariate and multivariate analyses (65.7 ± 12.8 vs. 59.7 ± 11.8, P = 0.002, odds ratio: 0.969, 95% confidence interval: 0.944-0.996). Among patients with hemoptysis, those requiring medical therapy and those requiring BAE were not significantly different in terms of demographic characteristics, radiographic manifestations, and distribution over 3 lobes. All patients who received BAE showed immediate clinical improvement, no procedure-related complications, and none of them died during the period under review. CONCLUSIONS: NTM lung disease patients commonly experienced hemoptysis without specific risk factors except for relatively young age. Although some patients with hemoptysis needed BAE, the success rate of BAE was high, and there were no serious complications associated with BAE.

Long-Term Mortality and Prognostic Factors in Aspiration Pneumonia.

OBJECTIVES: Aspiration pneumonia is a leading cause of death among older patients; however, little is known about the long-term mortality in aspiration pneumonia. The purpose of this study was to evaluate long-term mortality and its associated factors in patients with aspiration pneumonia. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: In total, 550 patients with aspiration pneumonia (median age: 78.0 years, 66.4% male) with compatible clinical symptoms and chest computed tomography images were enrolled at a single tertiary center from 2006 to 2016. MEASURES: The 1-, 3-, and 5-year mortality rates were evaluated for all patients. The prognostic factors for 1-year and 5-year mortality were also evaluated using Cox proportional hazard models. RESULTS: A total of 441 (80.2%) patients died during a median follow-up of 50.7 weeks. The 1-, 3-, and 5-year mortality rates were 49.0%, 67.1%, and 76.9%, respectively. Multivariate analysis identified 5 risk factors for 1-year mortality of male sex [hazard ratio (HR) 1.533, P = .003], low body mass index (HR 0.934, P = .002), hypoalbuminemia, anemia (0.973, P = .032), and mechanical ventilation (HR 2.052, P < .001), which were also independent prognostic factors for 5-year mortality. During the follow-up period, 133 (24.2%) patients experienced recurrent aspiration pneumonia. However, Kaplan-Meier analysis showed no significant differences in survival curves between patients with single and recurrent aspiration pneumonia (P = .371). CONCLUSIONS/IMPLICATIONS: Long-term prognosis of aspiration pneumonia was poor as a result of underlying morbidity instead of the aspiration pneumonia itself. Our findings suggest that prognostic indices for patients with aspiration pneumonia including the patient's underlying conditions should be devised.

Adenovirus pneumonia treated with Cidofovir in an immunocompetent high school senior.

Most adenovirus infections are self-limiting in immunocompetent individuals. Here, we report a case of adenovirus pneumonia in a 17-year-old immunocompetent male. He was admitted to our emergency room complaining of a febrile sense, cough, and diarrhea for four days. Crackles in the left lung and a high fever (40.7 °C) were revealed. Initial chest X-ray and computed tomography images showed consolidation in the left lung. We immediately started empirical antibiotic treatment, but his clinical symptoms and pneumonic consolidation in radiography had not improved by hospital day three. Because adenovirus was detected in his sputum using RT-PCR, he was administered Cidofovir. After 24 h of Cidofovir treatment, the symptoms and fever subsided, and the consolidation in his X-ray was significantly reduced by hospital day nine. The early administration of Cidofovir could be beneficial for the treatment of adenovirus infection in immunocompetent patients.

Clinical characteristics of patients with newly developed acute cholecystitis after admission to the intensive care unit.

INTRODUCTION: Critical care patients have many risk factors for acute cholecystitis (AC). However, less data are available regarding newly developed AC in critically ill patients. OBJECTIVES: To investigate the clinical features of AC occurring in critically ill patients after admission to an intensive care unit (ICU). METHODS: We performed a retrospective cohort study from January 2006 to August 2016 at a tertiary care university hospital. We included patients diagnosed with AC with or without gallstones after ICU admission. All cases of AC were confirmed by gastroenterologists or general surgeons. We excluded patients with AC diagnosed before or at the time of ICU admission. RESULTS: A total of 38 patients were diagnosed with AC after ICU admission between January 2006 and August 2016. Seventeen (44.7%) had acute acalculous cholecystitis, while 21 (55.3%) had acute calculous cholecystitis. The median age was 73 years (interquartile range = 63-81 years), and 22 (57.9%) patients were male. The most common reason for ICU admission was pneumonia or sepsis. The median interval from ICU admission to diagnosis of AC was 11 days (interquartile range = 4.8-22.8 days). Before AC diagnosis, almost 90% of patients used total parenteral nutrition, 68% used opioids, 76% were mechanically ventilated, and 42% received vasoactive drugs. More than half of patients underwent cholecystectomy, and all surgically resected gallbladders had pathology results for cholecystitis. Gangrenous cholecystitis was observed in five patients with acute calculous cholecystitis. The overall mortality was 42.1%, and 1/3 of these deaths were directly associated with AC. The average length of stay in the ICU and hospital was 26.5 and 44.5 days, respectively. CONCLUSION: The development of AC in the ICU should be carefully monitored, especially in patients who have been infected and admitted to the ICU for more than 10 days. Proper diagnosis and treatment at a critical time could be lifesaving.

Clinical outcomes and prognostic factors in patients directly transferred to the intensive care unit from long-term care beds in institutions and hospitals: a retrospective clinical study.

BACKGROUND: There has been a steady increase in the aging population and an increase in the need for long-term care beds in institutions and hospitals (LTCHs) in Korea. The aim of this study was to investigate prognosis and to identify factors contributing to mortality of critically ill patients with respiratory problems who were directly transferred to intensive care units (ICU) from LTCHs. METHODS: Following a retrospective review of clinical data and radiographic findings between July 2009 and September 2016, we included 111 patients with respiratory problems who had visited the emergency room (ER) transferred from LTCHs due to respiratory symptoms and who were then admitted to the ICU. RESULTS: The mean age of the 111 patients was 79 years, and 71 patients (64%) were male. Pneumonia developed in 98 patients (88.3%), pulmonary thromboembolism in 4 (3.6%) and pulmonary tuberculosis in 3 (2.7%). Overall mortality was 19.8% (22/111). Multiple-drug-resistant (MDR) pathogens (odds ratio [OR], 17.43; 95% confidence interval [CI], 1.96-155.40) and serum albumin levels < 2.15 g/dL, which were derived through ROC (sensitivity, 72.7%; specificity, 85.4%) (OR, 28.05; 95% CI, 5.47-143.75), were independent predictors for mortality. The need for invasive ventilation (OR, 2.74; 95% CI, 1.02-7.32) and history of antibiotic use within the 3 months (OR, 3.23; 95% CI, 1.32-7.90) were risk factors for harboring MDR pathogens. CONCLUSIONS: The presence of MDR pathogens and having low serum albumin levels may be poor prognostic factors in patients with respiratory problems who are admitted to the ICU from LTCHs. A history of antibiotic use within the 3 months and the need for invasive ventilation can be helpful in choosing the appropriate antibiotics to combat MDR pathogens at the time of admission.

Increased Risk of Exacerbation in Asthma Predominant Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome.

BACKGROUND: Obstructive airway disease patients with increased variability of airflow and incompletely reversible airflow obstruction are often categorized as having asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS). ACOS is heterogeneous with two sub-phenotypes: asthma-ACOS and COPD-ACOS. The objective of this study was to determine the difference in risk of exacerbation between the two sub-phenotypes of ACOS. METHODS: A total of 223 patients exhibiting incompletely reversible airflow obstruction with increased variability (spirometrically defined ACOS) were enrolled. These patients were divided into asthma-ACOS and COPD-ACOS according to their physician's diagnosis and smoking history of 10 pack-years. Within-group comparisons were made for asthma-ACOS versus COPD-ACOS and light smokers versus heavy smokers. RESULTS: Compared to patients with COPD-ACOS, patients with asthma-ACOS experienced exacerbation more often despite their younger age, history of light smoking, and better lung function. While the light-smoking group showed better lung function, they made unscheduled outpatient clinic visits more frequently. On multivariate analysis, asthma-ACOS and poor inhaler compliance were significantly associated with more than two unscheduled clinic visits during the previous year. CONCLUSION: Spirometrically defined ACOS includes heterogeneous subgroups with different clinical features. Phenotyping of ACOS by physician's diagnosis could be significant in predicting future risk of exacerbation.

High blood neutrophil-lymphocyte ratio associated with poor outcomes in miliary tuberculosis.

BACKGROUND: It is difficult to predict the prognosis of miliary tuberculosis (TB). We hypothesized that blood neutrophil-lymphocyte ratio (NLR) is an indicator of inflammatory status to reflect independent prognostic significance in patients with miliary TB. The aim of this study is to investigate the relationship between NLR and outcome in miliary TB. METHODS: We retrospectively collected data from patients diagnosed with miliary TB in a tertiary referral hospital between January 1995 and January 2016. RESULTS: A total of 96 patients were enrolled. Seventeen patients (18%) died during hospitalization due to miliary TB, and 9 (9%) died additionally during the 1-year follow-up period. Eighteen patients (19%) were diagnosed with acute respiratory distress syndrome (ARDS). In multiple logistic regression analyses, increased NLR was associated with ARDS [adjusted odds ratio, 1.15; 95% confidence interval (CI), 1.03-1.28]. By multivariate Cox regression analysis with adjustment of known prognostic factors including age, sex, body mass index, serum aspartate aminotransferase (AST), and hemoglobin, NLR was an independent predictor of in-hospital mortality [adjusted hazard ratio (aHR), 1.08; 95% CI, 1.03-1.13] and 1-year mortality (aHR, 1.08; 95% CI, 1.05-1.12). CONCLUSIONS: Pre-treatment NLR at admission may be a useful biomarker for mortality and development of ARDS in patients with miliary TB.

Diagnosis of small pulmonary lesions by transbronchial lung biopsy with radial endobronchial ultrasound and virtual bronchoscopic navigation versus CT-guided transthoracic needle biopsy: A systematic review and meta-analysis.

BACKGROUND: Advances in bronchoscopy and CT-guided lung biopsy have improved the evaluation of small pulmonary lesions (PLs), leading to an increase in preoperative histological diagnosis. We aimed to evaluate the efficacy and safety of transbronchial lung biopsy using radial endobronchial ultrasound and virtual bronchoscopic navigation (TBLB-rEBUS&VBN) and CT-guided transthoracic needle biopsy (CT-TNB) for tissue diagnosis of small PLs. METHODS: A systematic search was performed in five electronic databases, including MEDLINE, EMBASE, Cochrane Library Central Register of Controlled Trials, Web of Science, and Scopus, for relevant studies in May 2016; the selected articles were assessed using meta-analysis. The articles were limited to those published after 2000 that studied small PLs ≤ 3 cm in diameter. RESULTS: From 7345 records, 9 articles on the bronchoscopic (BR) approach and 15 articles on the percutaneous (PC) approach were selected. The pooled diagnostic yield was 75% (95% confidence interval [CI], 69-80) using the BR approach and 93% (95% CI, 90-96) using the PC approach. For PLs ≤ 2 cm, the PC approach (pooled diagnostic yield: 92%, 95% CI: 88-95) was superior to the BR approach (66%, 95% CI: 55-76). However, for PLs > 2 cm but ≤ 3 cm, the diagnostic yield using the BR approach was improved to 81% (95% CI, 75-85). Complications of pneumothorax and hemorrhage were rare with the BR approach but common with the PC approach. CONCLUSIONS: CT-TNB was superior to TBLB-rEBUS&VBN for the evaluation of small PLs. However, for lesions greater than 2 cm, the BR approach may be considered considering its diagnostic yield of over 80% and the low risk of procedure-related complications.

Combined silicosis and mixed dust pneumoconiosis with rapid progression: A case report and literature review.

BACKGROUND: Rapidly progressive pneumoconiosis (RPP) occasionally occurs in coal workers, particularly those with high exposure to silica. Here, we report the case of a 64-year-old male miller with RPP. CASE SUMMARY: The patient had a persistent cough for one month and had been clinically diagnosed with pulmonary tuberculosis in 2011. He worked in a stone processing factory from the ages of 20 through 37 and has owned his own mill for the past 25 years. His chest radiograph showed significant increases in the size and number of lung nodules since his last follow-up in 2013. By percutaneous needle lung biopsy, the nodular lesions showed diffuse infiltration of phagocytic macrophages and birefringent crystals by polarizing microscopy. He was finally diagnosed with RPP of mixed dust pneumoconiosis combined with silicosis. CONCLUSION: In this case, mixed dust pneumoconiosis with silicosis might be accelerated by persistent exposure to grain dust from working in a mill environment.

Hand grip strength and chronic obstructive pulmonary disease in Korea: an analysis in KNHANES VI.

BACKGROUND: Muscle mass is known to be associated with mortality in elderly adults. Because hand grip strength (HGS) is known as a simple assessment tool for muscular strength, many researchers have studied the association between HGS and disease. However, empirical evidence for the relationship between chronic obstructive pulmonary disease (COPD) and HGS is still controversial. The aim of this study was to evaluate the association between COPD and HGS, using Korean population data. METHODS: This was a population-based cross-sectional study. Data were obtained from the sixth Korean National Health and Nutrition Examination Survey, which was conducted from 2013 to 2015. To reduce the effects of HGS-related factors and potential confounding factors, propensity score matching was used to match subjects with and without COPD. RESULTS: Among 14,930 subjects, 832 were enrolled in each group (non-COPD and COPD) after propensity score matching. COPD subjects did not have lower HGS than non-COPD subjects (non-COPD vs COPD, male, 38.0±7.0 vs 38.9±7.0 kg, P=0.044, female, 23.8±4.6 vs 24.2±4.9 kg, P=0.342). Lung function was classified by Global Initiative for Chronic Obstructive Lung Disease stages and was not significantly associated with HGS. For male COPD subjects, there was a significant correlation between HGS and the EuroQol Five-Dimension Questionnaire (EQ5D) utility score index, which is an indicator of quality of life that adjusts for age and body mass index (r=0.201, P<0.001). The correlation was absent for female subjects (r=0.098, P=0.170). CONCLUSION: COPD subjects did not have lower HGS than non-COPD subjects. HGS did not associate with lung function. However, the HGS of male COPD subjects was positively associated with EQ5D utility score index, an indicator of quality of life. HGS may be helpful as an additional method to the evaluation of quality of life in male COPD patients.