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Background@#This study aimed to evaluate whether the effect of tachycardia varies according to the degree of tissue perfusion in septic shock. @*Methods@#Patients with septic shock admitted to the intensive care units were categorized into the tachycardia (heart rate > 100 beats/min) and non-tachycardia (≤ 100 beats/min) groups. The association of tachycardia with hospital mortality was evaluated in each subgroup with low and high lactate levels, which were identified through a subpopulation treatment effect pattern plot analysis. @*Results@#In overall patients, hospital mortality did not differ between the two groups (44.6% vs. 41.8%, P = 0.441), however, tachycardia was associated with reduced hospital mortality rates in patients with a lactate level ≥ 5.3 mmol/L (48.7% vs. 60.3%, P = 0.030; adjusted odds ratio [OR], 0.59, 95% confidence interval [CI], 0.35–0.99, P = 0.045), not in patients with a lactate level < 5.3 mmol/L (36.5% vs. 29.7%, P = 0.156; adjusted OR, 1.39, 95% CI, 0.82–2.35, P = 0.227). @*Conclusion@#In septic shock patients, the effect of tachycardia on hospital mortality differed by serum lactate level. Tachycardia was associated with better survival in patients with significantly elevated lactate levels.
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Background@#The quick sequential organ failure assessment (qSOFA) score is suggested to use for screening patients with a high risk of clinical deterioration in the general wards, which could simply be regarded as a general early warning score. However, comparison of unselected admissions to highlight the benefits of introducing qSOFA in hospitals already using Modified Early Warning Score (MEWS) remains unclear. We sought to compare qSOFA with MEWS for predicting clinical deterioration in general ward patients regardless of suspected infection. @*Methods@#The predictive performance of qSOFA and MEWS for in-hospital cardiac arrest (IHCA) or unexpected intensive care unit (ICU) transfer was compared with the areas under the receiver operating characteristic curve (AUC) analysis using the databases of vital signs collected from consecutive hospitalized adult patients over 12 months in five participating hospitals in Korea. @*Results@#Of 173,057 hospitalized patients included for analysis, 668 (0.39%) experienced the composite outcome. The discrimination for the composite outcome for MEWS (AUC, 0.777;95% confidence interval [CI], 0.770–0.781) was higher than that for qSOFA (AUC, 0.684;95% CI, 0.676–0.686; P < 0.001). In addition, MEWS was better for prediction of IHCA (AUC, 0.792; 95% CI, 0.781–0.795 vs. AUC, 0.640; 95% CI, 0.625–0.645; P < 0.001) and unexpected ICU transfer (AUC, 0.767; 95% CI, 0.760–0.773 vs. AUC, 0.716; 95% CI, 0.707–0.718; P < 0.001) than qSOFA. Using the MEWS at a cutoff of ≥ 5 would correctly reclassify 3.7% of patients from qSOFA score ≥ 2. Most patients met MEWS ≥ 5 criteria 13 hours before the composite outcome compared with 11 hours for qSOFA score ≥ 2. @*Conclusion@#MEWS is more accurate that qSOFA score for predicting IHCA or unexpected ICU transfer in patients outside the ICU. Our study suggests that qSOFA should not replace MEWS for identifying patients in the general wards at risk of poor outcome.
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Background and Objectives@#Despite recent improvements in advanced life support, the overall survival rate after cardiac arrest remains low. We aimed to examine the association of a multidisciplinary team approach with clinical outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation (ECPR) in the emergency department (ED). @*Methods@#This retrospective, single-center, observational study included 125 patients who underwent ECPR in the ED between May 2004–December 2018. In January 2014, our institution implemented a multidisciplinary extracorporeal membrane oxygenation (ECMO) team. Eligible patients were classified into pre-ECMO-team (n=65) and post-ECMO-team (n=60) groups. The primary outcome was in-hospital mortality. @*Results@#In-hospital mortality (72.3% vs. 58.3%, p=0.102) and poor neurological outcomes (78.5% vs. 68.3%, p=0.283) did not differ significantly between the pre- and post-ECMOteam groups. However, among the 60 patients who experienced in-hospital cardiac arrest,in-hospital mortality (75.8% vs. 40.7%, p=0.006) and poor neurological outcomes (78.8% vs. 48.1%, p=0.015) significantly decreased after the multidisciplinary team formation.Multivariable logistic regression analysis showed that the multidisciplinary team approach (adjusted odds ratio, 0.20; 95% confidence interval, 0.07–0.61; p=0.005) was an independent prognostic factor for in-hospital mortality in in-hospital cardiac arrest patients. @*Conclusions@#A multidisciplinary team approach was associated with improved clinical outcomes in in-hospital cardiac arrest patients undergoing ECPR in the ED. These findings may help in improving the selection criteria for ECPR in the ED. Further studies to overcome the study limitations may help improving the outcomes of out-of-hospital cardiac arrest patients.
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Background@#Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are significant public health issues in the world, but the epidemiological data pertaining to HAP/VAP is limited in Korea. The objective of this study was to investigate the characteristics, management, and clinical outcomes of HAP/VAP in Korea. @*Methods@#This study is a multicenter retrospective cohort study. In total, 206,372 adult patients, who were hospitalized at one of the 13 participating tertiary hospitals in Korea, were screened for eligibility during the six-month study period. Among them, we included patients who were diagnosed with HAP/VAP based on the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) definition for HAP/VAP. @*Results@#Using the IDSA/ATS diagnostic criteria, 526 patients were identified as HAP/VAP patients. Among them, 27.9% were diagnosed at the intensive care unit (ICU). The cohort of patients had a median age of 71.0 (range from 62.0 to 79.0) years. Most of the patients had a high risk of aspiration (63.3%). The pathogen involved was identified in 211 patients (40.1%). Furthermore, multidrug resistant (MDR) pathogens were isolated in 138 patients; the most common MDR pathogen was Acinetobacter baumannii. During hospitalization, 107 patients with HAP (28.2%) had to be admitted to the ICU for additional care. The hospital mortality rate was 28.1% in the cohort of this study. Among the 378 patients who survived, 54.2% were discharged and sent back home, while 45.8% were transferred to other hospitals or facilities. @*Conclusion@#This study found that the prevalence of HAP/VAP in adult hospitalized patients in Korea was 2.54/1,000 patients. In tertiary hospitals in Korea, patients with HAP/VAP were elderly and had a risk of aspiration, so they were often referred to step-down centers.
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Background@#Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are significant public health issues in the world, but the epidemiological data pertaining to HAP/VAP is limited in Korea. The objective of this study was to investigate the characteristics, management, and clinical outcomes of HAP/VAP in Korea. @*Methods@#This study is a multicenter retrospective cohort study. In total, 206,372 adult patients, who were hospitalized at one of the 13 participating tertiary hospitals in Korea, were screened for eligibility during the six-month study period. Among them, we included patients who were diagnosed with HAP/VAP based on the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) definition for HAP/VAP. @*Results@#Using the IDSA/ATS diagnostic criteria, 526 patients were identified as HAP/VAP patients. Among them, 27.9% were diagnosed at the intensive care unit (ICU). The cohort of patients had a median age of 71.0 (range from 62.0 to 79.0) years. Most of the patients had a high risk of aspiration (63.3%). The pathogen involved was identified in 211 patients (40.1%). Furthermore, multidrug resistant (MDR) pathogens were isolated in 138 patients; the most common MDR pathogen was Acinetobacter baumannii. During hospitalization, 107 patients with HAP (28.2%) had to be admitted to the ICU for additional care. The hospital mortality rate was 28.1% in the cohort of this study. Among the 378 patients who survived, 54.2% were discharged and sent back home, while 45.8% were transferred to other hospitals or facilities. @*Conclusion@#This study found that the prevalence of HAP/VAP in adult hospitalized patients in Korea was 2.54/1,000 patients. In tertiary hospitals in Korea, patients with HAP/VAP were elderly and had a risk of aspiration, so they were often referred to step-down centers.
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Purpose@#The diagnosis of pulmonary fungal infections is challenging due to the difficulty of obtaining sufficient specimens. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) needle rinse fluid has become an emerging diagnostic material. This study evaluated the role of routine fungal culture from EBUS-TBNA needle rinse fluid, in addition to histopathologic examination and fungal culture of EBUS-TBNA core tissue, in the diagnosis of pulmonary fungal infections. @*Materials and Methods@#Among patients who underwent EBUS-TBNA, those with results for at least one of three tests (histopathologic examination, fungal culture of EBUS-TBNA core tissue or needle rinse fluid) were included. Patients with a positive test were divided into two groups (clinical fungal infection and suspected fungal contamination) according to their clinical assessment and therapeutic response to antifungal. @*Results@#Of 6072 patients, 41 (0.7%) had positive fungal tests and 9 (22%) were diagnosed as clinical fungal infection. Of the 5222 patients who were evaluated using a fungal culture from EBUS-TBNA needle rinse fluid, 35 (0.7%) had positive results. However, only 4 out of 35 (11.4%) were classified as clinical fungal infection. Positive results were determined in 4 of the 68 (5.9%) evaluated by a fungal culture of EBUS-TBNA core tissue, and all were diagnosed as clinical fungal infection. @*Conclusion@#Routine fungal culture of EBUS-TBNA needle rinse fluid is not useful due to the low incidence of fungal infection and high rate of contamination. However, fungal culture of EBUS-TBNA core tissue and needle rinse fluid should be considered in patients with clinically suspected fungal infection.
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Background@#Despite the increasing importance of rehabilitation for critically ill patients, there is little information regarding how rehabilitation therapy is utilized in clinical practice. Our objectives were to evaluate the implementation rate of rehabilitation therapy in the intensive care unit (ICU) survivors and to investigate the effects of rehabilitation therapy on outcomes. @*Methods@#A retrospective nationwide cohort study with including > 18 years of ages admitted to ICU between January 2008 and May 2015 (n = 1,465,776). The analyzed outcomes were readmission to ICU readmission and emergency room (ER) visit. @*Results@#During the study period, 249,918 (17.1%) patients received rehabilitation therapy. The percentage of patients receiving any rehabilitation therapy increased annually from 14% in 2008 to 20% in 2014, and the percentages for each type of therapy also increased over time. The most common type of rehabilitation was physical therapy (91.9%), followed by neuromuscular electrical stimulation (29.6%), occupational (28.6%), respiratory, (11.6%) and swallowing (10.3%) therapies. After adjusting for confounding variables, the risk of 30-day ICU readmission was lower in patients who received rehabilitation therapy than in those who did not (P < 0.001; hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.65–0.75). And, the risk of 30-day ER visit was also lower in patients who received rehabilitation therapy (P < 0.001; HR, 0.83; 95% CI, 0.77–0.88). @*Conclusion@#In this nationwide cohort study in Korea, only 17% of all ICU patients received rehabilitation therapy. However, rehabilitation is associated with a significant reduction in the risk of 30-day ICU readmission and ER visit.
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This study investigated the changes in the major etiologic organisms and clinical phenotypes of nontuberculous mycobacterial lung disease (NTM-LD) over a recent 15-year period in Korea. The increase of number of patients with NTM-LD was primarily due to an increase of Mycobacterium avium complex (MAC) lung disease (LD). Among MAC cases, the proportion of M. avium increased compared with M. intracellulare, whereas the incidence of M. abscessus complex and M. kansasii LD remained relatively stable. The proportion of cases of the nodular bronchiectatic form increased compared with the fibrocavitary form of NTM-LD.
Subject(s)
Humans , Epidemiology , Incidence , Korea , Lung Diseases , Lung , Mycobacterium avium Complex , Mycobacterium kansasii , Nontuberculous Mycobacteria , Phenotype , Republic of Korea , Tertiary Care CentersABSTRACT
Intramural esophageal dissection is a rare but clinically important condition in the field of gastroenterology. Classically, intramural esophageal dissection rarely occurs in patients who are anticoagulated or have poor medical condition, and its clinical presentation may include chest pain, dysphagia and hematemesis. Herein, we present a case of intramural esophageal dissection in an alcoholic hepatitis patient that was diagnosed by endoscopy and successfully treated with conservative management.
Subject(s)
Humans , Male , Middle Aged , Deglutition Disorders/diagnosis , Enteral Nutrition , Esophageal Diseases/diagnosis , Esophagoscopy , Hepatitis, Alcoholic/pathology , Intubation, GastrointestinalABSTRACT
Neurilemmomas are relatively uncommon, slowly growing tumors which originate from Schwann cells. Intrathoracic neurilemmomas often occur in the chest wall and posterior mediastinum, but endobronchial neurilemmomas are exceedingly rare. These tumors in trachea or bronchus are usually detected by radiologic examinations, mostly computed tomography scan of chest. An 88-year-old man was admitted for management of pneumonia in left lower lobe and parapneumonic effusion. On bronchoscopic examination, there was a small polypoid nodule less than 1 cm in diameter mimicking an endobronchial inflammatory polyp at the bifurcation of the right anterior segmental bronchus and lateral segmental bronchus and under auto-fluorescence imaging, the nodule showed reddish brown area with defined margin. The bronchoscopic biopsy revealed that the bronchial nodule was endobronchial neurilemmoma. This is an interesting case of endobronchial neurilemmoma mimicking a bronchial polyp that is detected incidentally via bronchoscopy.