Mortality of severe septic patients between physician's high and low care volumes.

BACKGROUND: Patients with severe sepsis frequently require intensive care unit (ICU) admission and different ICU care models may influence their outcomes. The mortality of severe septic patients between physician's high and low care volume remains unclear. METHODS: We analyzed the data from a three-year prospective observation study, which was performed in an adult medical ICU of Chung Gung Memorial Hospital, Keelung. The data included initial bundle therapies based on the Surviving Sepsis Campaign (SSC) guidelines for patients with severe sepsis. RESULTS: Clinical data of total 484 patients with severe sepsis were recorded. Cox regression model showed that physician's care volume was an independent factor for lowering mortality in ICU patients with severe sepsis (hazard ratio 0.708; 95% confidence interval 0.514-0.974; p = 0.034). Patients treated by high care volume physician had four out of nine bundle therapies that were significantly higher in percentage following the SSC guidelines. These four therapies were renal replacement therapy, administration of low-dose steroids for septic shock, prophylaxis of gastro-intestinal bleeding, and control of hyperglycemia. CONCLUSION: High care volume physician may decrease mortality in ICU patients with severe sepsis through fitting bundle therapies for sepsis.

Liver Cirrhosis and Diabetes Mellitus Are Risk Factors for Staphylococcus aureus Infection in Patients with Healthcare-Associated or Hospital-Acquired Pneumonia.

BACKGROUND: The risk factors for Staphylococcus aureus (S. aureus) pneumonia are not fully identified. The aim of this work was to find out the clinical characteristics associated with S. aureus infection in patients with healthcare-associated pneumonia (HCAP) and hospital-acquired pneumonia (HAP), which may be applicable for more appropriate selection of empiric antibiotic therapy. METHODS: From July 2007 to June 2010, patients who were admitted to the intensive care unit with severe HCAP/HAP and severe sepsis were enrolled in this study. Lower respiratory tract sample was semiquantitatively cultured. Initial broad-spectrum antibiotics were chosen by Taiwan or American guidelines for pneumonia management. Standard bundle therapies were provided to all patients according to the guidelines of the Surviving Sepsis Campaign. RESULTS: The most frequently isolated pathogens were Pseudomonas aeruginosa, S. aureus, Acinetobacter baumannii, Klebsiella pneumoniae, and Escherichia coli. Patients with positive isolation of S. aureus in culture had significantly higher history of liver cirrhosis and diabetes mellitus, with odds ratios of 3.098 and 1.899, respectively. The S. aureus pneumonia was not correlated with history of chronic obstructive pulmonary disease, hypertension, and hemodialysis. CONCLUSION: Liver cirrhosis and diabetes mellitus may be risk factors for S. aureus infection in patients with severe HCAP or HAP.

Comparison of cardiovascular co-morbidities and CPAP use in patients with positional and non-positional mild obstructive sleep apnea.

BACKGROUND: This retrospective cohort study aimed to determine if there are differences in cardiovascular co-morbidities, blood pressure (BP) and continuous positive airway pressure (CPAP) use between patients with positional-dependent and nonpositional-dependent obstructive sleep apnea (OSA). METHODS: Patients who were referred for overnight polysomnography for suspected OSA between 2007 and 2011 were screened. A total of 371 patients with OSA were included for analysis and divided into six groups according to positional-dependency and severity of OSA: positional mild (n = 52), positional moderate (n = 29), positional severe (n = 24), non-positional mild (n = 18), non-positional moderate (n = 70) and non-positional severe group (n = 178). The six groups were compared for anthropometric and polysomnographic variables, presence of cardiovascular co-morbidities, morning and evening BP and the changes between evening and morning BP, and CPAP device usage patterns. RESULTS: Demographic and anthropometric variables showed non-positional severe OSA had poor sleep quality and higher morning blood pressures. Positional mild OSA had the lowest cardiovascular co-morbidities. Overall CPAP acceptance was 45.6%. Mild OSA patients had the lowest CPAP acceptance rate (10%), followed by moderate group (37.37%) and severe group (61.88%, P < 0.001). However, the significant difference in CPAP acceptance across OSA severity disappeared when the data was stratified by positional dependency. CONCLUSIONS: This study found that positional mild OSA had less cardiovascular co-morbidities compared with subjects with positional severe OSA. Independent of posture, CPAP acceptance in patients with mild OSA was low, but CPAP compliance was similar in CPAP acceptors regardless of posture dependency of OSA. Since there are increasing evidences of greater cardiovascular risk for untreated mild OSA, improving CPAP acceptance among mild OSA patients may be clinically important regardless of posture dependency.

Environmentally relevant exposure of 17α-ethinylestradiol impairs spawning and reproductive behavior in the brackish medaka Oryzias melastigma.

We assessed the effects of 17α-ethinylestradiol (EE2) on spawning and reproductive behavior of the brackish medaka Oryzias melastigma at environmental concentrations. Breeding pairs were exposed to EE2 at either lower concentrations (0, 1, and 10 ng/L) or higher concentrations (0, 50, and 100 ng/L) for 14 days. Swimming performance and reproductive behavior (following, dancing, and copulation) of the males were analyzed at the end of exposure. Additionally, gonad histology was conducted in the males in the higher EE2 experiment. We found that spawning was significantly inhibited in the 50-100 ng/L EE2 groups. Swimming performance was not affected in all groups. Dancing and copulation were significantly suppressed in the 50-100 ng/L groups. No effect was observed in testis histology in the 50-100 ng/L groups. Our data suggests that reproductive behavior of O. melastigma can be utilized as a behavioral endpoint for ecotoxicology studies of endocrine disruptors in estuarine/marine environments.

Associations of T helper 1, 2, 17 and regulatory T lymphocytes with mortality in severe sepsis.

OBJECTIVE AND DESIGN: T helper 17 (Th17) and regulatory T (Treg) lymphocytes might play important roles in patients with severe sepsis. The association of Th17 or Treg lymphocytes with survival is also unclear. METHODS: Eighty-seven patients with severe sepsis were enrolled from our intensive care units between August 2008 and July 2010. Leukocyte antigens and clinical data were determined on day 1 in all patients and on day 7 in first-year patients. RESULTS: The percentages in peripheral blood mononuclear cells (PBMCs) and circulatory counts of CD4⁺ and CD8⁺ lymphocytes in survivors were higher than those in non-survivors. Th1/CD4⁺ ratios and circulatory Th1 lymphocyte counts in survivors were higher than in non-survivors. Absolute counts of Th17 and Treg lymphocytes in survivors were higher than in non-survivors. The percentages of CD4⁺ and CD8⁺ in survivors' PBMCs were increased after 6 days. Th17/CD4⁺ ratios and circulatory Th17 lymphocyte counts in survivors were increased after 6 days. CONCLUSIONS: Higher Th1 differentiation and total CD4⁺ T lymphocyte counts were associated with higher survival. The association of circulatory Th17 and Treg lymphocytes with mortality in severe sepsis may be due to the change in total CD4⁺ T lymphocytes. In survivors, Th17 differentiation and counts were restored.

Factors affecting CPAP acceptance in elderly patients with obstructive sleep apnea in Taiwan.

BACKGROUND: The prevalence of obstructive sleep apnea (OSA) increases with age. Treatment often includes CPAP. CPAP adherence is correlated with disease severity and symptoms. We hypothesized that CPAP acceptance rates in elderly patients with OSA would be lower than in younger patients with OSA, and examined factors associated with CPAP acceptance. METHODS: We reviewed the charts of 315 subjects with OSA (apnea-hypopnea index ≥ 5 events/h) who were treated at our hospital from 2008 to 2011 with CPAP therapy. All underwent CPAP titration testing before CPAP prescription. Subjects were grouped by age: young (25-40 y, n = 35), middle-age (41-65 y, n = 169), and elderly (> 65 y, n = 111). Demographic variables, excessive daytime sleepiness, overnight polysomnography study variables, CPAP acceptance, and CPAP adherence were compared. Regression analysis was performed to identify factors associated with acceptance. RESULTS: The elderly subjects had less excessive daytime sleepiness and less pronounced alterations in overnight polysomnography variables than the subjects in the other groups, but had more cardiovascular comorbidities. The CPAP acceptance rate (overall 125/315, 39.7%) was significantly lower in the elderly group, compared with the younger group (31.5% vs 60%, P = .01). CPAP acceptance was associated with fewer comorbidities, higher excessive daytime sleepiness, and higher apnea-hypopnea index, but not age. CPAP adherence was not associated with age. CONCLUSIONS: CPAP acceptance is low in elderly patients in Taiwan. CPAP acceptance, instead of CPAP adherence, is the critical issue with elderly patients with OSA.

Fish fin aspiration: an unusual type of lower airway foreign body in a Chinese adult.

Foreign body aspiration into the lower airway is rare in adults, and typically occurs in individuals of advanced age or with underlying neurological or medical conditions. The most common type of lower airway foreign body is organic substances, in particular chicken or fish bones. In many patients a history of an acute choking event is not found, and symptoms are non-specific and may be attributed to other medical conditions. Herein we report the unique case of an 80-year-old Chinese woman who aspirated a fish fin that was undiagnosed for 3 years.

Factors that affect the diagnostic yield of endobronchial ultrasonography-assisted transbronchial lung biopsy.

BACKGROUND: Endobronchial ultrasound (EBUS) is a relatively noninvasive procedure used to diagnose and stage lung cancer. Although EBUS-guided transbronchial lung biopsy (TBLB) procedures for peripheral lesions have higher diagnostic yields than traditional TBLB or fluoroscopy-assisted TBLB, the diagnostic yield is not 100%, and the reasons for this are not clear. SUBJECTS AND METHODS: This retrospective study assessed what characteristics influence the diagnostic yield of EBUS-guided TBLB. EBUS was used to locate a single peripheral lung nodule or mass, and the lesion was biopsied and pathologically characterized. Parameters that were evaluated included patient demographics, lesion location, ease of tumor sampling, location of the EBUS probe relative to the lesion, pathological volume, tumor cell type, and whether physicians were under supervision. RESULTS: Thirty-nine patients received EBUS-guided TBLB, which correctly identified 76.9% of the patients as having lung cancer. For the remaining patients, subsequent surgery indicated their tumors were malignant. Univariate logistic regression modeling indicated that only the location of the probe relative to the lesion was significantly associated with diagnostic yield of EBUS-guided TBLB. When the probe was directly within the lesion, it was 8.17 times (odds ratio 8.17; 95% confidence interval 1.41, 47.22; P=.019) more likely to have a successful TBLB than when the probe was adjacent to the lesion. CONCLUSIONS: In this study, the position of the probe relative to a peripheral lung lesion was associated with the diagnostic yield of EBUS-guided TBLB. Larger prospective studies are required to further assess what influences the diagnostic yield of this technology.

PTEN overexpression attenuates angiogenic processes of endothelial cells by blockade of endothelin-1/endothelin B receptor signaling.

Arteriovenous (AV) graft is frequently used as vascular access in hemodialysis patients. However, clotting or thrombosis of AV grafts often occurs and requires surgical removal. At present, the molecular pathogenesis underlying thrombosis of AV graft is not clear. The PTEN/Akt signaling has been implicated in the pathogenesis of vascular diseases. In this study, elevated PTEN expression and concomitant Akt inactivation was observed in endothelium of atherosclerotic brachial arteries from hemodialysis patients. To investigate whether PTEN upregulation affects endothelial function, adenovirus-mediated PTEN (Ad-PTEN) overexpression was performed in aorta rings and cultured endothelial cells. It was found that PTEN overexpression potently inhibited the microvessel sprouting in aorta rings and the angiogenic activities of endothelial cells including migration and tube formation. On the contrary, PTEN knockdown by RNA interference promoted the endothelial migration and reversed the Ad-PTEN-induced inhibition of endothelial migration. Expression analysis showed that PTEN overexpression attenuated the expression of endothelin-1 (ET-1) and endothelin B receptor (ETBR) in endothelial cells at transcriptional levels. However, exogenous ET-1 supply only partially reversed the PTEN-induced inhibition of migration and tube formation. This was delineated due to that PTEN overexpression also perturbed endothelial nitric oxide synthase (eNOS) activation and vascular endothelial growth factor (VEGF) release. In summary, PTEN upregulation induces endothelial dysfunction by attenuating the availability and signaling of multiple angiogenic pathways in endothelial cells, thereby may contribute to thrombosis of AV graft.

Ocular examination for diagnosis of end stage pulmonary sarcoidosis.

PURPOSE: Pulmonary sarcoidosis without overt radiographic fibrosis may be difficult to diagnose; ophthalmic examination aided diagnosis of our case. CASE REPORT: The patient was a 55-year-old man whose dyspnea had been misdiagnosed and who had been treated for chronic obstructive pulmonary disease. Physical and ophthalmic examinations including slitlamp, fundoscopic, and fluorescein angiography examinations were administered. CONCLUSIONS: Patient's ophthalmic findings suggested ocular sarcoidosis, leading to confirmation of his pulmonary sarcoidosis by histopathological examination of lung biopsy samples. Careful, knowledgeable ophthalmic examination can help in diagnosing systemic sarcoidosis.

Serial increase of IL-12 response and human leukocyte antigen-DR expression in severe sepsis survivors.

INTRODUCTION: Sepsis-induced immunosuppression may result in death. The mechanisms of immune suppression include loss of macrophage and monocyte expression of the major histocompatibility complex, increased anti-inflammatory cytokine expression and decreased expression of proinflammatory cytokines. In this study, we sought to determine the mechanisms of immune suppression in severe sepsis by repeated detection. METHODS: We designed this prospective observational study to measure monocyte human leukocyte antigen (HLA)-DR expression, plasma cytokine levels and cytokine responses on days 1 and 7 in stimulated peripheral blood mononuclear cells (PBMCs) of healthy controls and patients with severe sepsis. RESULTS: Of the 35 enrolled patients, 23 survived for 28 days and 12 died, 6 of whom died within 7 days. Plasma levels of IL-1ß, IL-6, IL-10, IL-17, transforming growth factor (TGF)-ß1 and TNF-α were higher, but plasma IL-12 level was lower in septic patients than those in controls. Day 1 plasma levels of IL-1ß, IL-6, IL-10 and TGF-ß1 in nonsurvivors were higher than those in survivors. Day 7 plasma IL-10 levels in nonsurvivors were higher than in survivors. IL-1ß response was higher, but IL-12 and TNF-α responses were lower in septic patients than in controls. Day 1 IL-6 response was lower, but day 1 TGF-ß1 response was higher in nonsurvivors than in survivors. Plasma IL-6 and IL-10 levels were decreased in survivors after 6 days. IL-6 response was decreased in survivors after 6 days, but IL-12 response was increased. Monocyte percentage was higher, but positive HLA-DR percentage in monocytes and mean fluorescence intensity (MFI) of HLA-DR were lower in septic patients than in controls. MFI of HLA-DR was increased in survivors after 6 days. CONCLUSIONS: Monocyte HLA-DR expression and IL-12 response from PBMCs are restored in patients who survive severe sepsis.

Behavioral effects of titanium dioxide nanoparticles on larval zebrafish (Danio rerio).

In this study, zebrafish embryos were exposed to titanium dioxide nanoparticles (TiO2 NPs at 0.1, 0.5, 1, 5, 10 mg/L or control) from fertilization to free swimming stage. Hatchability, survival, and malformation rate were not affected by TiO2 NPs at these exposure levels. However, larval swimming parameters, including average and maximum velocity and activity level were significantly affected by TiO2 NPs. Co-exposure to either the glutathione precursor, N-acetylcysteine (NAC), or the glutathione synthesis inhibitor, buthionine sulfoximine (BSO), did not significantly alter the behavioral effects resulting from TiO2 NPs, suggesting that other factor(s) besides oxidative stress may contribute to the behavioral toxicity of TiO2 NPs. Our study also demonstrated that the behavioral endpoints were more sensitive than the others (e.g., hatchability and survival) to detect toxicity of TiO2 NPs on developing fish.

Performance of European system for cardiac operative risk evaluation in Veterans General Hospital Kaohsiung cardiac surgery.

BACKGROUND: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) model is a widely-used risk prediction algorithm for in-hospital or 30-day mortality in adult cardiac surgery patients. Recent studies indicated that EuroSCORE tends to overpredict mortality. The aim of our study is to evaluate the validity of EuroSCORE in Veterans General Hospital Kaohsiung (VGHKS) cardiac surgery including a number of different surgical and risk subgroups. METHODS: From January 2006 to December 2009, 1,240 adult patients who underwent cardiac surgery in VGHKS were included in this study. The study was followed the guidelines of the Ethics Committee of Kaohsiung Veterans General Hospital, Taiwan. Both additive and logistic score of all patients were calculated depending on the formula in the official EuroSCORE website. The entire cohort, different surgical type and risk stratification subgroups were analyzed. Model discrimination was tested by determining the area under receiver operating characteristic (ROC) curve. Model calibration was tested by the Hosmer-Lemeshow chi-square test. Clinical performance of model was assessed by comparing the observed and predicted mortality rates. RESULTS: There were significant differences between the VGHKS and European cardiac surgical populations. The additive score and logistic score for the overall group were 7.16% and 12.88%, respectively. Observed mortality was 10.72% overall, 5.68% for isolated coronary artery bypass grafting (CABG), 4.67% for the mitral valve only and 4.25% for the aortic valve only group. The discriminative ability EuroSCORE was very good in all and various surgical subgroups, with area under the ROC curve from 0.75 to 0.87. The addictive and logistic models of EuroSCORE showed excellent accuracy, 0.839 and 0.845, respectively. Good calibration power was recognized by p value higher than 0.05 for the entire cohort and all subgroups of patients except for isolated CABG. The logistic EuroSCORE model overestimated mortality to different degrees in the various subgroups, indicating that the logistic EuroSCORE needs to be recalibrated by a factor about 0.55 for uncomplicated surgery and low-risk groups, and 0.85 for high-risk patients with original additive score more than six. CONCLUSION: EuroSCORE is simple and easy to use. In the present study, the model demonstrated excellent accuracy in all and various surgical subgroups in VGHKS cardiovascular surgery populations. Good calibration ability in all and different risk categories was identified except for isolated CABG group. Recalibration factors of 0.55 and 0.85 were suggested for the various operative subgroups and risk categories.

Supplementary catechins attenuate cooking-oil-fumes-induced oxidative stress in rat lung.

Cooking-oil-fumes containing toxic components may induce reactive oxygen species (ROS) to oxidize macromolecules and lead to acute lung injury. Our previous study showed that a decaffineated green tea extract containing (+)-catechin, (-)-epicatechin, (+)-gallocatechin, (-)-epigallocatechin, (-)-epicatechin gallate, and (-)-epigallocatechin gallate can inhibit oxidation, inflammation, and apoptosis. We determined whether the catechins supplement may reduce cooking-oil-fumes-induced acute lung injury in rat. In the urethane-anesthetized Wistar rat subjected to 30-120 min of cooking-oil-fumes exposure, blood ROS significantly increased in the recovery stage. After 30-min cooking-oil-fumes exposure, the enhanced blood ROS level further increased in a time-dependent manner during the recovery stage (321 +/- 69 counts/10 s after 1 h, 540 +/- 89 counts/10 s after 2 h, and 873 +/- 112 counts/10 s after 4 h). Four hours after 30-min cooking-oil-fumes exposure, lung lavage neutrophils and ROS as well as lung tissue dityrosine and 4-hydroxy-2-nonenal increased significantly. Two weeks of catechins supplememnt significantly reduced the enhanced lavage ROS, lung dityrosine and 4-hydroxy-2-nonenal level. Cooking-oil-fumes-induced oxidative stress decreased lung Bcl-2/Bax ratio and HSP70 expression, but catechins treatment preserved the downregulation of Bcl-2/Bax ratio and HSP70 expression. We conclude that catechins supplement attenuates cooking-oil-fumes-induced acute lung injury via the preservation of oil-smoke induced downregulation of antioxidant, antiapoptosis, and chaperone protein expression.

Main pulmonary artery aneurysm.

Pulmonary artery aneurysm is a rare lesion of the thoracic cavity. Different etiologies have been reviewed, but idiopathic lesions without other symptoms are seldom reported. Usually, surgical interventions are suggested, but the long-term outcomes are not well established. Here, we report a 24-year-old man with main pulmonary artery aneurysm who successfully underwent aneurysmectomy and polytetrafluoroethylene vascular graft replacement. The postoperative course was uneventful, and the following image study revealed normal size of the great vessels.

Duodenal obstruction after elective abdominal aortic aneurysm repair: a case report.

Gastrointestinal tract complications after abdominal aortic aneurysm (AAA) repair are well known. The reported frequency ranges from 6.6% to 21%. However, the incidence of duodenal obstruction following AAA has probably been underestimated. This report concerns a 78-year-old male who was admitted for elective repair of an infrarenal AAA. On the ninth postoperative day, the patient presented with large quantities of bile-stained vomitus despite passing flatus per rectum. Metoclopramide and ranitidine were given under the initial impression of paralytic ileus. However, the upper gastrointestinal obstruction persisted, and on day 12, computerized tomography (CT) revealed marked distension of the gastric tube and duodenum, down to the level of the third portion, with abrupt change of caliber at the point of the superior mesenteric artery (SMA). SMA syndrome was diagnosed. After nasogastric tube aspiration, parenteral nutrition, and 11 days of conservative treatment, abdominal CT and upper gastrointestinal series showed no apparent duodenal obstruction. The patient was discharged on the 29th postoperative day; follow-up abdominal CT 4 months later was unremarkable.