Fontan-associated plastic bronchitis waitlist and heart transplant outcomes: A PHTS analysis.

Plastic bronchitis is a rare post-Fontan complication with limited treatment options. Heart transplantation has evolved as a potential curative option, but outcomes have not been well-defined. This study aims to assess contemporary waitlist and post-transplant outcomes in patients with plastic bronchitis. All Fontan patients were identified in the PHTS database (2010 - 2018). Waitlist and post-transplant outcomes were compared between Fontan patients with and without plastic bronchitis. Competing outcomes and Kaplan-Meier analyses were used to assess the impact of plastic bronchitis on waitlist and post-transplant survival. A secondary analysis excluded those with PLE from the comparison cohort. Of 645 Fontan patients listed for heart transplant, 69 (11%) had plastic bronchitis. At listing, patients with plastic bronchitis were younger (8.9 vs 11.1 years, P = .02), but had few other differences in baseline characteristics. A fewer Fontan patients with plastic bronchitis were listed in the more recent era (46 [15.4%] in 2010-2014 vs 23 [6.6%] in 2015-2018, P < .01). Overall, there was no difference in waitlist (P = .30) or post-transplant (P = .66) survival for Fontan patients with and without plastic bronchitis. The results were similar after excluding patients with PLE. Contrary to prior reports, this relatively large series showed that plastic bronchitis did not have a negative impact on survival to or after heart transplantation in Fontan patients. Our study also found a 50% reduction in listing in the current era, which may indicate evolution in management of Fontan patients.

Protein-losing enteropathy and plastic bronchitis after the Fontan procedure.

OBJECTIVES: Protein losing enteropathy and plastic bronchitis are severe complications in Fontan circulation, with 5-year survival ranging from 46% to 88%. We report risk factors and outcomes of protein losing enteropathy and plastic bronchitis in patients undergoing the Fontan. METHODS: We performed a retrospective analysis of 1561 patients from the Australia New Zealand Fontan Registry. Two end points were death and cardiac transplantation examined with Cox regression (if no competing risks) or cumulative incidence curves and cause-specific Cs regression. RESULTS: A total of 55 patients with protein losing enteropathy/plastic bronchitis were included. Their median age at the Fontan was 5.7 years, and time to onset after the Fontan for protein losing enteropathy was 5.0 years and plastic bronchitis was 1.7 years. Independent predictors for developing protein losing enteropathy/plastic bronchitis were right-ventricular morphology with hypoplastic left-heart syndrome (hazard ratio, 2.30; confidence interval, 1.12-4.74), older age at Fontan (hazard ratio, 1.13; confidence interval, 1.03-1.23), and pleural effusions after Fontan (hazard ratio, 2.43; confidence interval, 1.09-5.41); left-ventricular morphology was protective (hazard ratio, 0.36; confidence interval, 0.18-0.70). In the protein losing enteropathy/plastic bronchitis population, freedom from death or transplantation after protein losing enteropathy/plastic bronchitis diagnosis at 5, 10, and 15 years was 70% (confidence interval, 58-85), 65% (confidence interval, 51-83), and 43% (confidence interval, 26-73), respectively; only older age (hazard ratio, 1.23; confidence interval, 1.01-1.52) was an independent predictor. Twenty-six surgical interventions were performed in 20 patients, comprising Fontan revisions (n = 5), fenestrations (n = 11), Fontan conversions (n = 5), atrioventricular valve repairs (n = 3), and hepatic vein diversion (n = 2). CONCLUSIONS: Protein losing enteropathy and plastic bronchitis remain severe complications, preferably affecting patients with dominant right single ventricle, with older age at Fontan being a predictor of developing protein losing enteropathy/plastic bronchitis and poorer prognosis. Heart transplantation remains the ultimate treatment, with 30% dying or requiring transplantation within 5 years, and the remaining being stable for long periods.

Lower Respiratory Tract Infection and Short-Term Outcome in Patients With Acute Respiratory Distress Syndrome.

OBJECTIVE: To assess whether ventilator-associated lower respiratory tract infections (VA-LRTIs) are associated with mortality in critically ill patients with acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS: Post hoc analysis of prospective cohort study including mechanically ventilated patients from a multicenter prospective observational study (TAVeM study); VA-LRTI was defined as either ventilator-associated tracheobronchitis (VAT) or ventilator-associated pneumonia (VAP) based on clinical criteria and microbiological confirmation. Association between intensive care unit (ICU) mortality in patients having ARDS with and without VA-LRTI was assessed through logistic regression controlling for relevant confounders. Association between VA-LRTI and duration of mechanical ventilation and ICU stay was assessed through competing risk analysis. Contribution of VA-LRTI to a mortality model over time was assessed through sequential random forest models. RESULTS: The cohort included 2960 patients of which 524 fulfilled criteria for ARDS; 21% had VA-LRTI (VAT = 10.3% and VAP = 10.7%). After controlling for illness severity and baseline health status, we could not find an association between VA-LRTI and ICU mortality (odds ratio: 1.07; 95% confidence interval: 0.62-1.83; P = .796); VA-LRTI was also not associated with prolonged ICU length of stay or duration of mechanical ventilation. The relative contribution of VA-LRTI to the random forest mortality model remained constant during time. The attributable VA-LRTI mortality for ARDS was higher than the attributable mortality for VA-LRTI alone. CONCLUSION: After controlling for relevant confounders, we could not find an association between occurrence of VA-LRTI and ICU mortality in patients with ARDS.

Estudio caso-control del impacto clínico de la traqueobronquitis asociada a la ventilación mecánica en pacientes adultos, que no desarrollan neumonía asociada a ventilación mecánica / A case-control study on the clinical impact of ventilator associated tracheobronchitis in adult patients who did not develop ventilator associated pneumonia

Objetivos: El objetivo primario fue determinar si la traqueobronquitis asociada a ventilación mecánica (TAV) está asociada con un aumento de estancia en UCI. Los objetivos secundarios incluyeron prolongación de estancia hospitalaria, así como mortalidad en UCI y hospitalaria. Diseño: Estudio retrospectivo caso-control. Apareamos cada caso con un control en base a los siguientes criterios: periodo de VM al menos tan extenso, como el tiempo en que el caso desarrolla la TAV ± 2 días, gravedad evaluada por la escala APACHE II al ingreso en UCI, igual ± 3, igual motivo de ingreso del paciente, igual edad ± 10 años. Pacientes: Pacientes adultos ingresados en una UCI polivalente de 30 camas, con el diagnóstico de TAV en el periodo 2013-2016. Resultados: Identificamos 76 pacientes con TAV que ingresaron en UCI en el periodo de estudio. No se encontraron controles adecuados para 3 pacientes con TAV. No se encontraron diferencias significativas entre ambos grupos en cuanto a características demográficas, motivo de ingreso y comorbilidades. La estancia media en UCI de los pacientes con traqueobronquitis asociada a ventilación mecánica fue más prolongada en los casos que en los controles, mediana 22d (14-35), comparada con los controles mediana 15d (8-27), p=0,02. Los casos presentaron mayor número de días de VM respecto a los controles, mediana 18 días (9-28) vs. 9 días (5-16) p = 0,03. No encontramos diferencias significativas respecto a la estancia hospitalaria 40d (28-61) vs. 35d (23-54), p= 0,32; mortalidad en UCI (20,5 vs. 31,5% p=0,13) y mortalidad hospitalaria (30,1 vs. 43,8% p= 0,09). Realizamos un análisis del subgrupo de pacientes con TAV con documentación microbiológica y tratamiento empírico adecuado sin encontrar diferencias significativas en ninguno de los aspectos analizados. Conclusiones: La TAV, prolonga los días de estancia en UCI y de ventilación mecánica. Este efecto desaparece cuando los pacientes reciben tratamiento empírico adecuado

Objectives: The main objective was to determine whether ventilator-associated tracheobronchitis (VAT) is related to increased length of ICU stay. Secondary endpoints included prolongation of hospital stay, as well as, ICU and hospital mortality. Design: A retrospective matched case-control study. Each case was matched with a control for duration of ventilation (± 2 days until development of ventilator-associated tracheobronchitis), disease severity (Acute Physiology and Chronic Health Evaluation II) at admission ± 3, diagnostic category and age ±10 years. Patients: Critically ill adults admitted to a polyvalent 30-beds ICU with the diagnosis of VAT in the period 2013-2016. Main results: We identified 76 cases of VAT admitted to our ICU during the study period. No adequate controls were found for 3 patients with VAT. There were no significant differences in demographic characteristics, reasons for admission and comorbidities. Patients with VAT had a longer ICU length of stay, median 22 days (14-35), compared to controls, median 15 days (8-27), p=.02. Ventilator days were also significantly increased in VAT patients, median 18 (9-28) versus 9 days (5-16), p=.03. There was no significant difference in total hospital length of stay 40 (28-61) vs. 35days (23-54), p=.32; ICU mortality (20.5 vs. 31.5% p=.13) and hospital mortality (30.1 vs. 43.8% p=.09). We performed a subanalysis of patients with microbiologically proven VAT receiving adequate antimicrobial treatment and did not observe significant differences between cases and the corresponding controls. Conclusions: VAT is associated with increased length of intensive care unit stay and longer duration of mechanical ventilation. This effect disappears when patients receive appropriate empirical treatment

A case-control study on the clinical impact of ventilator associated tracheobronchitis in adult patients who did not develop ventilator associated pneumonia. / Estudio caso-control del impacto clínico de la traqueobronquitis asociada a la ventilación mecánica en pacientes adultos, que no desarrollan neumonía asociada a ventilación mecánica.

OBJECTIVES: The main objective was to determine whether ventilator-associated tracheobronchitis (VAT) is related to increased length of ICU stay. Secondary endpoints included prolongation of hospital stay, as well as, ICU and hospital mortality. DESIGN: A retrospective matched case-control study. Each case was matched with a control for duration of ventilation (± 2 days until development of ventilator-associated tracheobronchitis), disease severity (Acute Physiology and Chronic Health Evaluation II) at admission ± 3, diagnostic category and age ±10 years. PATIENTS: Critically ill adults admitted to a polyvalent 30-beds ICU with the diagnosis of VAT in the period 2013-2016. MAIN RESULTS: We identified 76 cases of VAT admitted to our ICU during the study period. No adequate controls were found for 3 patients with VAT. There were no significant differences in demographic characteristics, reasons for admission and comorbidities. Patients with VAT had a longer ICU length of stay, median 22 days (14-35), compared to controls, median 15 days (8-27), p=.02. Ventilator days were also significantly increased in VAT patients, median 18 (9-28) versus 9 days (5-16), p=.03. There was no significant difference in total hospital length of stay 40 (28-61) vs. 35days (23-54), p=.32; ICU mortality (20.5 vs. 31.5% p=.13) and hospital mortality (30.1 vs. 43.8% p=.09). We performed a subanalysis of patients with microbiologically proven VAT receiving adequate antimicrobial treatment and did not observe significant differences between cases and the corresponding controls. CONCLUSIONS: VAT is associated with increased length of intensive care unit stay and longer duration of mechanical ventilation. This effect disappears when patients receive appropriate empirical treatment.

Continuous versus intermittent endotracheal cuff pressure control for the prevention of ventilator-associated respiratory infections in Vietnam: study protocol for a randomised controlled trial.

BACKGROUND: Ventilator-associated respiratory infection (VARI) comprises ventilator-associated pneumonia (VAP) and ventilator-associated tracheobronchitis (VAT). Although their diagnostic criteria vary, together these are the most common hospital-acquired infections in intensive care units (ICUs) worldwide, responsible for a large proportion of antibiotic use within ICUs. Evidence-based strategies for the prevention of VARI in resource-limited settings are lacking. Preventing the leakage of oropharyngeal secretions into the lung using continuous endotracheal cuff pressure control is a promising strategy. The aim of this study is to investigate the efficacy of automated, continuous endotracheal cuff pressure control in preventing the development of VARI and reducing antibiotic use in ICUs in Vietnam. METHODS/DESIGN: This is an open-label randomised controlled multicentre trial. We will enrol 600 adult patients intubated for ≤ 24 h at the time of enrolment. Eligible patients will be stratified according to admission diagnosis (180 tetanus, 420 non-tetanus) and site and will be randomised in a 1:1 ratio to receive either (1) automated, continuous control of endotracheal cuff pressure or (2) intermittent measurement and control of endotracheal cuff pressure using a manual cuff pressure meter. The primary outcome is the occurrence of VARI, defined as either VAP or VAT during the ICU admission up to a maximum of 90 days after randomisation. Patients in both groups who are at risk for VARI will receive a standardised battery of investigations if their treating physician feels a new infection has occurred, the results of which will be used by an endpoint review committee, blinded to the allocated arm and independent of patient care, to determine the primary outcome. All enrolled patients will be followed for mortality and endotracheal tube cuff-related complications at 28 days and 90 days after randomisation. Other secondary outcomes include antibiotic use; days ventilated, in ICU and in hospital; inpatient mortality; costs of antibiotics in ICU; duration of ICU stay; and duration of hospital stay. DISCUSSION: This study will provide high-quality evidence concerning the use of continuous endotracheal cuff pressure control as a method to reduce VARI, antibiotic use and hospitalisation costs and to shorten stay. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02966392 . Registered on November 9, 2016. Protocol version: 2.0; issue date March 3, 2017.

Risk factors for mortality in ventilator-associated tracheobronchitis: a case-control study.

Objective: To describe the microbiological characteristics and to assess the risk factors for mortality of ventilator-associated tracheobronchitis in a case-control study of intensive care patients. Methods: This case-control study was conducted over a 6-year period in a 40-bed medical-surgical intensive care unit in a tertiary care, private hospital in São Paulo, Brazil. Case patients were identified using the Nosocomial Infection Control Committee database. For the analysis of risk factors, matched control subjects were selected from the same institution at a 1:8.8 ratio, between January 2006 and December 2011. Results: A total of 40 episodes of ventilator-associated tracheobronchitis were evaluated in 40 patients in the intensive care unit, and 354 intensive care patients who did not experience tracheobronchitis were included as the Control Group. During the 6-year study period, a total of 42 organisms were identified (polymicrobial infections were 5%) and 88.2% of all the microorganisms identified were Gram-negative. Using a logistic regression model, we found the following independent risk factors for mortality in ventilator-associated tracheobronchitis patients: Acute Physiology and Chronic Health Evaluation I score (odds ratio 1.18 per unit of score; 95%CI: 1.05-1.38; p=0.01), and duration of mechanical ventilation (odds ratio 1.09 per day of mechanical ventilation; 95%CI: 1.03-1.17; p=0.004). Conclusion: Our study provided insight into the risk factors for mortality and microbiological characteristics of ventilator-associated tracheobronchitis.

Objetivo: Descrever as características microbiológicas e avaliar os fatores de risco para mortalidade na traqueobronquite associada à ventilação mecânica em um estudo caso-controle de pacientes de terapia intensiva. Métodos: Estudo realizado ao longo de 6 anos em uma unidade de terapia intensiva médico-cirúrgica de 40 leitos, em um hospital privado e de nível terciário em São Paulo, Brasil. O Grupo Caso foi identificado usando o banco de dados da Comissão de Controle de Infecção Hospitalar. O Grupo Controle foi pareado na proporção de 1:8,8 entre janeiro de 2006 e dezembro de 2011. Resultados: Quarenta episódios de traqueobronquites associadas à ventilação foram avaliados em 40 pacientes na unidade de terapia intensiva, e 354 pacientes não apresentaram traqueobronquite Grupo Controle. Foram identificados 42 microrganismos (dos quais 5% foram infecções polimicrobianas), sendo que 88,2% de todos os microrganismos eram bactérias Gram-negativas. Usando um modelo de regressão logística, encontramos os seguintes fatores de risco independentes para mortalidade em pacientes com traqueobronquites associadas à ventilação: pontuação da Acute Physiology and Chronic Health Evaluation I (odds ratio 1,18 por uma unidade de pontuação; IC95%: 1,05-1,38; p=0,01) e duração da ventilação mecânica (odds ratio 1,09 por dia de ventilação mecânica; IC95%: 1,03-1,17; p=0,004). Conclusão: Nosso estudo forneceu informações sobre os fatores de risco para mortalidade e características microbiológicas da traqueobronquite associada à ventilação mecânica.

Risk factors for mortality in ventilator-associated tracheobronchitis: a case-control study / Fatores de risco para mortalidade em traqueobronquite associada à ventilação mecânica: estudo caso-controle

ABSTRACT Objective To describe the microbiological characteristics and to assess the risk factors for mortality of ventilator-associated tracheobronchitis in a case-control study of intensive care patients. Methods This case-control study was conducted over a 6-year period in a 40-bed medical-surgical intensive care unit in a tertiary care, private hospital in São Paulo, Brazil. Case patients were identified using the Nosocomial Infection Control Committee database. For the analysis of risk factors, matched control subjects were selected from the same institution at a 1:8.8 ratio, between January 2006 and December 2011. Results A total of 40 episodes of ventilator-associated tracheobronchitis were evaluated in 40 patients in the intensive care unit, and 354 intensive care patients who did not experience tracheobronchitis were included as the Control Group. During the 6-year study period, a total of 42 organisms were identified (polymicrobial infections were 5%) and 88.2% of all the microorganisms identified were Gram-negative. Using a logistic regression model, we found the following independent risk factors for mortality in ventilator-associated tracheobronchitis patients: Acute Physiology and Chronic Health Evaluation I score (odds ratio 1.18 per unit of score; 95%CI: 1.05-1.38; p=0.01), and duration of mechanical ventilation (odds ratio 1.09 per day of mechanical ventilation; 95%CI: 1.03-1.17; p=0.004). Conclusion Our study provided insight into the risk factors for mortality and microbiological characteristics of ventilator-associated tracheobronchitis.

RESUMO Objetivo Descrever as características microbiológicas e avaliar os fatores de risco para mortalidade na traqueobronquite associada à ventilação mecânica em um estudo caso-controle de pacientes de terapia intensiva. Métodos Estudo realizado ao longo de 6 anos em uma unidade de terapia intensiva médico-cirúrgica de 40 leitos, em um hospital privado e de nível terciário em São Paulo, Brasil. O Grupo Caso foi identificado usando o banco de dados da Comissão de Controle de Infecção Hospitalar. O Grupo Controle foi pareado na proporção de 1:8,8 entre janeiro de 2006 e dezembro de 2011. Resultados Quarenta episódios de traqueobronquites associadas à ventilação foram avaliados em 40 pacientes na unidade de terapia intensiva, e 354 pacientes não apresentaram traqueobronquite Grupo Controle. Foram identificados 42 microrganismos (dos quais 5% foram infecções polimicrobianas), sendo que 88,2% de todos os microrganismos eram bactérias Gram-negativas. Usando um modelo de regressão logística, encontramos os seguintes fatores de risco independentes para mortalidade em pacientes com traqueobronquites associadas à ventilação: pontuação da Acute Physiology and Chronic Health Evaluation I (odds ratio 1,18 por uma unidade de pontuação; IC95%: 1,05-1,38; p=0,01) e duração da ventilação mecânica (odds ratio 1,09 por dia de ventilação mecânica; IC95%: 1,03-1,17; p=0,004). Conclusão Nosso estudo forneceu informações sobre os fatores de risco para mortalidade e características microbiológicas da traqueobronquite associada à ventilação mecânica.

Risk factors and outcome of Fontan-associated plastic bronchitis: a case-control study.

BACKGROUND: The onset of plastic bronchitis (PB) can be debilitating in survivors of Fontan surgery. The rarity of this complication makes designing studies to understand risk factors for PB challenging. This 2-center case-control study aimed to describe patient outcomes and to assess the association of antecedent patient factors with PB development. METHODS AND RESULTS: Using center registries, PB patients (n=25) were matched 1:2 to non-PB Fontans (n=43) by date of Fontan surgery and center. The groups were compared for baseline characteristics. Association of patient characteristics with PB was assessed using logistic regression and of potential risk factors with onset of PB using time-to-event analyses. The median time from Fontan to PB diagnosis was 2.5 years. Overall, 12/25 PB patients died or underwent heart transplant; the median transplant-free survival was 8.3 years after diagnosis. Factors associated with developing PB included post-surgical chylothorax (44% PB versus 10% control; odds ratio [OR] 7.3; P=0.003), chest tube (CT) duration at stage 2 (P=0.04) and Fontan (P=0.004), and postoperative ascites (36% PB versus 12% control; OR 4.2; P=0.003). CT drainage >13 days at Fontan was associated with earlier PB onset (P=0.04). Early-onset PB was associated with an increased risk of death (OR 5.0; P=0.002). CONCLUSIONS: PB is a life-threatening disorder. A longer duration of CT drainage after surgery, chylothorax, and development of ascites are all associated with developing PB. Understanding the pathophysiology of peri-operative complications in individual patients and using targeted interventions may delay the onset of the PB phenotype.

Mortality and causes of deaths of inhabitants with renal dysfunction induced by cadmium exposure of the polluted Jinzu River basin, Toyama, Japan; a 26-year follow-up.

BACKGROUND: We aimed to investigate the mortality and causes of deaths of inhabitants with renal dysfunction induced by cadmium (Cd) exposure caused by heavy environmental contamination. METHODS: We conducted a 26-year follow-up survey targeting 7529 inhabitants of the Cd-polluted Jinzu River basin and 2149 controls from non-polluted areas who participated in urinary examinations for proteinuria and glucosuria conducted in 1979 to 1984. When the residents were divided into 4 groups, no finding group, glucosuria group, proteinuria group, glucoproteinuria group, mortality risk ratios for all and specific causes of these groups in the polluted area were compared with that of controls without glucosuria and/or proteinuria after adjustments for age at baseline, smoking status, and history of hypertension using Cox's proportional hazard model. RESULTS: The mortality risk ratios for all causes of proteinuria and glucoproteinuria in men and glucosuria, proteinuria, and glucoproteinuria in women of the polluted areas significantly increased compared with those of the controls with no urinary findings. Respiratory, renal, and cardiovascular diseases and diabetes in men, and all diseases except cerebrovascular diseases in women contributed toward an increased mortality of exposed glucoproteinuria groups, which involved chronic Cd toxicosis with renal tubular dysfunction. In women, the mortality risks for cancer of the colon and rectum, uterus and kidney and urinary tract were significantly higher in the exposed proteinuria and glucoproteinuria groups, suggesting associations between renal damage and cancer risk. In exposed women, the no finding group and glucoproteinuria group also showed increased mortality from ischemic heart diseases, indicating that all exposed women may be at risk for ischemic heart diseases. Although the control glucosuria and/or proteinuria group also showed high mortality for diabetes and renal diseases, the increased risk ratio for renal disease mortality was much higher in exposed subjects with urinary findings, particularly in women. CONCLUSIONS: These findings indicate that inhabitants with renal effects caused by Cd exposure had a poor life prognosis over long-term observation in both genders. Particularly in women, renal tubular dysfunction indicated by glucoproteinuria may increase mortality from cancer, ischemic heart diseases, and renal diseases.

Thrombocytopenia: an early marker of late mortality in type B aortic dissection.

Mid-term and long-term mortality after aortic dissection remain high and due to unknown factors. To determine predicting factors at the acute phase associated with mid- and long-term all-cause mortality, patients with type B aortic dissection including intramural hematoma, treated in one referral university center in an area with a population of 4 million, were analyzed over a period of 12 years (from 1996 to 2008). Based on the total population, 77 patients discharged after type B aortic dissection (including 11 intramural hematoma) were recorded as treated with either medical treatment alone (n = 41) or with additional endovascular therapy (n = 36). The mean follow-up period was 50.8 months, with a survival rate of 78 % (17 deaths). Patient history, symptoms, medical treatment, biological parameters, imaging, and intervention during acute phase (more than 150 parameters) were analyzed to identify any relationship with complications and death. Kaplan-Meier survival curve and Cox proportional hazards analyses identified independent predictors of follow-up mortality from any cause. Factors influencing mortality (P < 0.05) were a low systolic blood pressure (SBP) at admission, a thrombocytopenia in the acute period, chronic bronchitis, diameter of ascending aorta, and renin-angiotensin system inhibitor intake. Independent predictors of mortality were chronic bronchitis (P = 0.0022, hazard ratio (HR) 17.5), early thrombocytopenia (P = 0.042, HR 3.5), and admission SBP <120 mmHg (P = 0.0048, HR 7.928). Treated (medical ± endovascular) type B aortic dissection held a worse long-term prognosis, which can be correlated with predicting factors, especially in-hospital thrombocytopenia, and should require closer follow-up.

ß-Blockers and All-Cause Mortality in Adults with Episodes of Acute Bronchitis: An Observational Study.

BACKGROUND: Recent observational studies suggest that ß-blockers may improve long-term prognosis in patients with chronic obstructive pulmonary disease (COPD). We assessed whether ß-blocker use improves all-cause mortality in patients with episodes of acute bronchitis. METHODS: An observational cohort study using data from the electronic medical records of 23 general practices in the Netherlands. The data included standardized information about daily patient contacts, diagnoses, and drug prescriptions. Cox regression was applied with time-varying treatment and covariates. RESULTS: The study included 4,493 patients aged 45 years and older, with at least one episode of acute bronchitis between 1996 and 2006. The mean (SD) age of the patients was 66.9 (11.7) years, and 41.9% were male. During a mean (SD) follow up period of 7.7 (2.5) years, 20.4% developed COPD. In total, 22.7% had cardiovascular comorbidities, resulting in significant higher mortality rates than those without (51.7% vs. 12.0%, p<0.001). The adjusted hazard ratio of cardioselective ß-blocker use for mortality was 0.62 (95% confidence interval [CI], 0.50-0.77), and 1.01 (95% CI 0.75-1.36) for non-selective ones. Some other cardiovascular drugs also reduced the risk of mortality, with adjusted HRs of 0.60 (95% CI 0.46-0.79) for calcium channel blockers, 0.88 (95% CI 0.73-1.06) for ACE inhibitors/angiotensin receptor blockers, and 0.42 (95% CI 0.31-0.57) for statins, respectively. CONCLUSION: Cardiovascular comorbidities are common and increase the risk of mortality in adults with episodes of acute bronchitis. Cardioselective ß-blockers, but also calcium channel blockers and statins may reduce mortality, possibly as a result of cardiovascular protective properties.

Ventilator-associated tracheobronchitis increases the length of intensive care unit stay.

OBJECTIVE: To investigate prospectively the clinical course and risk factors for ventilator-associated tracheobronchitis (VAT) and the impact of VAT on intensive care unit (ICU) morbidity and mortality. DESIGN: Prospective cohort study. SETTING: University Hospital Larissa, Larissa, Greece. PATIENTS: Critical care patients who received mechanical ventilation for more than 48 hours were prospectively studied between 2009 and 2011. METHODS: The modified Clinical Pulmonary Infection Score, white blood cell count, and C-reactive protein level were systematically assessed every 2 days for the first 2 weeks of ICU stay. Bronchial secretions were assessed daily. Quantitative cultures of endotracheal secretions were performed on the first ICU day for every patient and every 2 days thereafter for the first 2 weeks or more at the discretion of the attending physicians. Definition of VAT was based on previously published criteria. RESULTS: A total of 236 patients were observed; 42 patients (18%) presented with VAT. Gram-negative pathogens, which were usually multidrug resistant, were responsible for 92.9% of cases. Patients with a neurosurgical admission presented with VAT significantly more often than did other ICU patients (28.5% vs 14.1%; . The occurrence P=.02) of VAT was a significant risk factor for increased duration of ICU stay (OR [95% CI], 3.04 [1.35­6.85]; P=.01). Age (OR [95% CI], 1.04 [1.015­1.06]; P=.02), Acute Physiology and Chronic Health Evaluation II score (OR [95% CI], 1.08 [1.015­1.16]; P=.02), and C-reactive protein level at admission (OR [95% CI], 1.05 [1.01­1.1]; P=.02) were independent factors for ICU mortality. CONCLUSIONS: VAT is a nosocomial infection that might be associated with prolonged stay in the ICU, especially in neurocritical patients. VAT was not associated with increased mortality in our study.

Long-term health experience of jet engine manufacturing workers: IX. further investigation of general mortality patterns in relation to workplace exposures.

OBJECTIVE: To evaluate mortality rates among a cohort of jet engine manufacturing workers. METHODS: Subjects were 222,123 workers employed from 1952 to 2001. Vital status was determined through 2004 for 99% of subjects and cause of death for 95% of 68,317 deaths. We computed standardized mortality ratios and modeled internal cohort rates. RESULTS: Mortality excesses reported initially no longer met the criteria for further investigation. We found two chronic obstructive pulmonary disease-related mortality excesses that met the criteria in two of eight study plants. CONCLUSIONS: At the total cohort level, chronic obstructive pulmonary disease-related categories were not related to any factors or occupational exposures considered. A full evaluation of these excesses was limited by lack of data on smoking history. Occupational exposures received outside of work or uncontrolled positive confounding by smoking cannot be ruled out as reasons for these excesses.

Ventilator-associated tracheobronchitis in a mixed medical/surgical pediatric ICU.

BACKGROUND: Adult studies have demonstrated that ventilator-associated tracheobronchitis (VAT) may be a precursor to ventilator-associated pneumonia (VAP). No published data on VAT in pediatric ICUs (PICUs) were found. The purposes of this retrospective, descriptive study are to describe the incidence, characteristics, and outcomes of patients at risk for VAT and formalize a process of VAT surveillance in the PICU population. METHODS: All patients meeting criteria for VAT during 2009-2010 were reviewed and data collected on risk of mortality, index of mortality, interventions, demographic data, respiratory cultures, and the organisms identified in culture. RESULTS: Of 645 patients (32.7%) admitted who met mechanical ventilation criteria, 22 (3.4%) met criteria for VAT. Patients with VAT experienced a significantly longer mean length of stay in the PICU (27.6±22.043 days vs 6.61±7.27 days; P=.000) and higher mean total ventilator time (519.31±457.60 h vs 95.60±138.83 h; P=.000). There was a significant association between tracheostomy and VAT (P=.000) and between chronic ventilator dependence and VAT (P=.002). Gram-negative rods accounted for 71% of cultured microorganisms; staphylococcal or streptococcal species were identified as 26% of causative pathogens. Six of 25 (24%) VAT events identified two or more potentially causative pathogens; four of these (67%) were in patients with a tracheostomy. CONCLUSIONS: VAT occurred less frequently in our PICU than reported in adult studies, and no cases of VAT progressed to VAP in our population. Our results suggest that VAT is a clinically significant health-care-associated infection in the PICU population.

Comparison of polymyxin B with other antimicrobials in the treatment of ventilator-associated pneumonia and tracheobronchitis caused by Pseudomonas aeruginosa or Acinetobacter baumannii.

PURPOSE: This study was designed to compare the efficacy of polymyxin B with other antimicrobials in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis (VAT) by Pseudomonas aeruginosa or Acinetobacter baumannii. METHODS: A prospective cohort study was performed. Patients >18 years of age with the diagnosis of VAP or VAT who received appropriate therapy for >48 h were analyzed. The primary outcome was 30-day mortality. Clinical covariates were assessed and compared between the groups. RESULTS: A total of 67 episodes were analyzed: 45 (67 %) treated with polymyxin B and 22 (33 %) with comparators. The crude 30-day mortality was 53 % (24 of 45) in the polymyxin B group and 27 % (6 of 22) in the comparator group (P = 0.08). Multivariable analysis using Cox regression models indicated that polymyxin B treatment was independently associated with increased mortality. CONCLUSIONS: Polymyxin B treatment in the currently recommended dosage may be inferior to other drugs in the treatment of VAP and VAT caused by organisms tested as susceptible in vitro to this agent.

Relationship between "purulent bronchitis" in military populations in Europe prior to 1918 and the 1918-1919 influenza pandemic.

Purulent bronchitis was a distinctive and apparently new lethal respiratory infection in British and American soldiers during the First World War. Mortality records suggest that purulent bronchitis caused localized outbreaks in the midst of a broad epidemic wave of lethal respiratory illness in 1916-1917. Probable purulent bronchitis deaths in the Australian Army showed an epidemic wave that moved from France to England. Purulent bronchitis may have been the clinical expression of infection with a novel influenza virus which also could have been a direct precursor of the 1918 pandemic strain.

Respiratory tract infections after cardiac surgery: impact on hospital morbidity and mortality.

AIM: Nosocomial pneumonia (NP) and tracheobronchitis after cardiac surgery are associated with worse outcomes. The aim of this study was to identify risk factors associated with NP and tracheobronchitis after cardiac surgery and to determine the impact of these infections on hospital morbidity and mortality. METHODS: We evaluated 1600 adult patients undergoing cardiac surgery under standard cardiopulmonary bypass. Data were collected prospectively. All NP and tracheobronchitis episodes were confirmed by a semiquantitative culture of endotracheal aspirate. Logistic regression analysis was done to identify risk factors for respiratory tract infection and mortality. RESULTS: The rate of NP was 1.2% (15.6 episodes per 1000 days of mechanical ventilation) and that of tracheobronchitis was 1.6% (21 episodes per 1000 days of mechanical ventilation). Significant independent risk factors for respiratory tract infection (pneumonia or tracheobronchitis) were: left ventricular ejection fraction < 30% (P = 0.001), chronic renal failure (P < 0.0001) and urgent surgery (P < 0.0001). Patients with NP had significantly higher mortality (42% versus 0.9%, P < 0.0001) than patients without respiratory tract infection. The median hospital length of stay was significantly longer in patients with pneumonia (42 days) and tracheobronchitis (28 days) than in patients without any respiratory tract infection (11 days, P < 0.0001). CONCLUSION: NP after cardiac surgery is associated with severe outcomes. Independent risk markers for respiratory tract infection were left ventricular ejection fraction < 30%, chronic renal failure and urgent surgery.

[Epidemiology and development of prophylaxis of acute respiratory diseases and pneumonias in servicemen in modern conditions].

Acute diseases of respiratory organs occupy leading position among all diseases in army. In 2009 a part of total morbidity of ARD, flu, pneumonia and acute bronchitis was 45.7% from all diseases. With the start of the usage of pneumococcal vaccine in the army continuous increase of morbidity of pneumonia gave way to reduction. In postvaccinal period in patients with pneumonia, frequency of pneumococcus's effuse reduced under the increase of frequency of detection of viruses, staphylococcus and streptococcus. Considering polyaetiology of pneumonia and ARD, significancy of immune inefficiency in its developments, it is necessary to use specific prophylactic drugs with antiviral products in period of reinforce.