Occurrence of Intracranial Hemorrhage and Associated Risk Factors in Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy:A Systematic Review and Meta-Analysis

Background@#and Purpose Intracranial hemorrhage (ICH) is thought to be a rare but probably underestimated presentation of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). We conducted a systematic review and meta-analysis with the aim of comprehensively revealing the occurrence of ICH in patients with CADASIL. @*Methods@#English-language studies published up to September 30, 2021 were searched for in the MEDLINE (PubMed), Web of Science, and Cochrane Library databases. The design, patient characteristics, occurrence rate of ICH, and associated risk factors were retrieved for each identified relevant study. @*Results@#We enrolled 13 studies in the final meta-analysis, which included 1,310 patients with CADASIL. The probability of ICH occurrence in patients with CADASIL was 10.1% (95% confidence interval [CI]=5.6%–18.0%, I2 =85.1%). When stratified by geographic region, the occurrence rate of ICH was much higher in Asians (17.7%; 95% CI=11.0%–28.5%, I2 =76.3%) than in Europeans (2.0%; 95% CI=0.4%–10.8%, I2 =82.8%). A higher burden of cerebral microbleeds (CMBs) and a history of hypertension were the most commonly recorded risk factors for ICH, which were available for three and two of the included studies, respectively. @*Conclusions@#Our study suggests that ICH is an important clinical manifestation of CADASIL, especially in Asians. A higher burden of CMBs and the existence of hypertension were found to be associated with a higher probability of ICH occurrence in patients with CADASIL.

Clinical analysis of non-tuberculous mycobacterial pulmonary diseases in patients with mechanical ventilation / 中华危重病急救医学

To study the risk factors and the clinical characteristics of non-tuberculous mycobacterial (NTM) pulmonary diseases in patients with mechanical ventilation. Methods Retrospective survey was carried out in the patients with mechanical ventilation who combined with NTM pulmonary disease admitted to intensive care unit (ICU) of the First Affiliated Hospital of Guangzhou Medical University from May 2016 to May 2019. The general information, basic diseases, symptoms, signs, biochemical examinations, acid-fast stain test, mycobacterium culture and strain identification results, and chest CT data were collected to summarize the clinical characteristics of patients with mechanical ventilation combined with NTM pulmonary disease. Results There were 12 patients with mechanical ventilation combined with NTM pulmonary disease, 6 males and 6 females, 37-82 years old, with an average age of 65 years. In these 12 cases, patients with cancer (lung cancer were 4 cases, mediastinal tumor was 1 case) and after lung transplantation (use of anti-rejection drugs at the same time) were 5 and 2 respectively. Patients with at least 3 underlying diseases [included hypertension, diabetes, coronary heart disease, chronic obstructive pulmonary disease (COPD), bronchiectasis, chronic renal insufficiency] were 5. Clinical symptoms of the 12 cases were non-specific. The CT findings were not characteristic, including nodules, patchy infiltrations and fibrous streak. Pleural effusion was common among these subjects but nodular bronchiectatic patterns were absence. Routine laboratory indicators of bacterial infection were non-specific. But the number of lymphocytes of all cases decreased. Mycobacteria cultures were positive with the rapid growth of mycobacteria in these 12 cases. Mycobacterium avium (4 cases), Mycobacterium chelonae (4 cases), Mycobacterium chelonae-abscessus complex (2 cases) and Mycobacterium intracellulare (2 cases) were isolated. Anti-NTM therapy was given to the patients when the acid-fast staining test of their airway secretion was positive and the TB-DNA test was negative, including oral levofloxacin and clarithromycin. Finally, all patients were successfully weaned and discharged from ICU. Conclusions The clinical symptoms of NTM patients with pulmonary disease are non-specific, and the imaging features of chest CT are varied. Patients with mechanical ventilation in ICU, who have the risk of immune dysfunction or underlying structural lung diseases, and who have difficult controlled lung infection, accompanied by pleural effusion and with decreased lymphocytes, should be aware that pneumonia may be caused by non-tuberculous mycobacteria.

Cause of massive hemoptysis in critical patients and the effect of bronchial artery embolization / 中华危重病急救医学

OBJECTIVE@#To investigate the cause of massive hemoptysis in critical patients, and to evaluate the effect of bronchial artery embolization (BAE) on critical patients with massive hemoptysis.@*METHODS@#A retrospective controlled analysis was conducted. The clinical data of 35 patients with life-threatening massive hemoptysis admitted to intensive care unit (ICU) of the First Hospital Affiliated to Guangzhou Medical University from January 2009 to December 2017 were analyzed. The patients were divided into BAE and non-BAE group according to whether receiving BAE or not. BAE patients were subdivided into subgroups: hemoptysis after ventilation and hemoptysis before ventilation subgroups, as well as survival and non-survival subgroups. The etiology of all massive hemoptysis was analyzed. The gender, age, acute physiology and chronic health evaluation II (APACHE II) score, amount of hemoptysis, whether presence of pleural thickening in chest CT, the length of ICU stay, total length of hospital stay, the duration of mechanical ventilation (MV), clinical effective and prognostic indicators of patients were recorded. The correlation between variables was analyzed by Spearman correlation analysis.@*RESULTS@#All 35 patients were enrolled in the finally analysis. The main cause of critical patients with massive hemoptysis was fungal infection [37.1% (13/35)], followed by pneumonia and abnormal coagulation [17.1% (6/35)], bronchiectasis [11.4% (4/35)], tumor [8.6% (3/35)], etc. In all 35 patients, 27 were treated with BAE and 8 were treated without BAE. There was no difference in gender, age, the length of ICU stay, total length of hospital stay, the duration of MV, amount of hemoptysis, APACHE II score, whether use antiplatelet agents or anticoagulants, or whether presence of pleural thickening in chest CT between the two groups. The rate of hemoptysis remission in BAE group was significantly higher than that of non-BAE group [92.6% (25/27) vs. 25.0% (2/8), P < 0.01], but there was no statistically significant difference in hospital survival as compared with that of non-BAE group [48.1% (13/27) vs. 25.0% (2/8), P > 0.05]. Subgroup analysis showed that 64.3% (9/14) of patients with hemoptysis after ventilation was caused by pulmonary fungal infection, which was significantly higher than those with hemoptysis before ventilation [15.4% (2/13), P = 0.018]. Compared with hemoptysis after ventilation group, the length of ICU stay and the duration of MV in hemoptysis before ventilation group were significantly shortened [the length of ICU stay (days): 12.0 (14.0) vs. 30.0 (81.8), the duration of MV (days): 10.0 (16.0) vs. 25.0 (68.3)], the patients using antiplatelet drugs or anticoagulant drugs was decreased significantly (case: 1 vs. 9, all P < 0.05). However, there was no statistically significant difference in gender, age, total length of hospital stay, amount of hemoptysis, APACHE II score, whether presence of pleural thickening in chest CT, the rate of hemoptysis remission, the incidence of secondary BAE or hospital survival rate between the two groups. Compared with the survival subgroup (n = 13), more patients in the non-survival subgroup (n = 14) were treated with antiplatelet or anticoagulants (P < 0.05); and Spearman correlation analysis showed that the survival of the patients with BAE was negatively correlated with the use of antiplatelet or anticoagulants (r = -0.432, P = 0.024). There was no significant difference in the gender, age, the length of ICU day, total length of hospitalization, duration of MV, estimated hemoptysis, APACHE II score, or the proportion of pleural thickening between the two groups.@*CONCLUSIONS@#The study indicated that the etiology of massive hemoptysis in critical patients was complicated. Fungal infection was the main cause in patients with hemoptysis after ventilation. BAE was effective in the control of massive hemoptysis in ICU, but it was not ideal for patients with abnormal coagulation function or abnormal platelet count or platelet dysfunction from antiplatelet or anticoagulant drugs, the overall survival rate was still low.

Cause of massive hemoptysis in critical patients and the effect of bronchial artery embolization / 中华危重病急救医学

Objective@#To investigate the cause of massive hemoptysis in critical patients, and to evaluate the effect of bronchial artery embolization (BAE) on critical patients with massive hemoptysis.@*Methods@#A retrospective controlled analysis was conducted. The clinical data of 35 patients with life-threatening massive hemoptysis admitted to intensive care unit (ICU) of the First Hospital Affiliated to Guangzhou Medical University from January 2009 to December 2017 were analyzed. The patients were divided into BAE and non-BAE group according to whether receiving BAE or not. BAE patients were subdivided into subgroups: hemoptysis after ventilation and hemoptysis before ventilation subgroups, as well as survival and non-survival subgroups. The etiology of all massive hemoptysis was analyzed. The gender, age, acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score, amount of hemoptysis, whether presence of pleural thickening in chest CT, the length of ICU stay, total length of hospital stay, the duration of mechanical ventilation (MV), clinical effective and prognostic indicators of patients were recorded. The correlation between variables was analyzed by Spearman correlation analysis.@*Results@#All 35 patients were enrolled in the finally analysis. The main cause of critical patients with massive hemoptysis was fungal infection [37.1% (13/35)], followed by pneumonia and abnormal coagulation [17.1% (6/35)], bronchiectasis [11.4% (4/35)], tumor [8.6% (3/35)], etc. In all 35 patients, 27 were treated with BAE and 8 were treated without BAE. There was no difference in gender, age, the length of ICU stay, total length of hospital stay, the duration of MV, amount of hemoptysis, APACHEⅡ score, whether use antiplatelet agents or anticoagulants, or whether presence of pleural thickening in chest CT between the two groups. The rate of hemoptysis remission in BAE group was significantly higher than that of non-BAE group [92.6% (25/27) vs. 25.0% (2/8), P < 0.01], but there was no statistically significant difference in hospital survival as compared with that of non-BAE group [48.1% (13/27) vs. 25.0% (2/8), P > 0.05]. Subgroup analysis showed that 64.3% (9/14) of patients with hemoptysis after ventilation was caused by pulmonary fungal infection, which was significantly higher than those with hemoptysis before ventilation [15.4% (2/13), P = 0.018]. Compared with hemoptysis after ventilation group, the length of ICU stay and the duration of MV in hemoptysis before ventilation group were significantly shortened [the length of ICU stay (days): 12.0 (14.0) vs. 30.0 (81.8), the duration of MV (days): 10.0 (16.0) vs. 25.0 (68.3)], the patients using antiplatelet drugs or anticoagulant drugs was decreased significantly (case: 1 vs. 9, all P < 0.05). However, there was no statistically significant difference in gender, age, total length of hospital stay, amount of hemoptysis, APACHEⅡ score, whether presence of pleural thickening in chest CT, the rate of hemoptysis remission, the incidence of secondary BAE or hospital survival rate between the two groups. Compared with the survival subgroup (n = 13), more patients in the non-survival subgroup (n = 14) were treated with antiplatelet or anticoagulants (P < 0.05); and Spearman correlation analysis showed that the survival of the patients with BAE was negatively correlated with the use of antiplatelet or anticoagulants (r = -0.432, P = 0.024). There was no significant difference in the gender, age, the length of ICU day, total length of hospitalization, duration of MV, estimated hemoptysis, APACHE Ⅱ score, or the proportion of pleural thickening between the two groups.@*Conclusions@#The study indicated that the etiology of massive hemoptysis in critical patients was complicated. Fungal infection was the main cause in patients with hemoptysis after ventilation. BAE was effective in the control of massive hemoptysis in ICU, but it was not ideal for patients with abnormal coagulation function or abnormal platelet count or platelet dysfunction from antiplatelet or anticoagulant drugs, the overall survival rate was still low.

An Intratracheal Challenge Murine Model of Asthma: Can Bronchial Inflammation Affect the Nose?

PURPOSE: Extensive data support the influence of the upper airway on lower airway inflammation and pathophysiology in allergic disease. However, few studies have focused on allergic inflammation in the nose after an isolated lower airway allergen challenge, a situation that can exist clinically when human subjects breathe primarily through the mouth, as occurs when nasally congested. This study used a mouse model to investigate whether upper airway inflammation and hyperresponsiveness were induced by an isolated lower airway allergen challenge. METHODS: BALB/c mice were sensitized by systemic intraperitoneal injection of ovalbumin/saline and challenged with intratracheal ovalbumin/saline. Inflammation in the nose and lungs was assessed by cytology and histology of nasal tissues and bronchoalveolar lavage fluid (BALF), while nasal airway resistance and response were measured over 3 days post-challenge. RESULTS: Intratracheal application of an allergen in anaesthetized mice resulted in exclusive deposition in the lower airway. Compared to control animals, ovalbumin-sensitized mice after challenge showed bronchial hyperreactivity and increased IL-5 in the serum BALF, as well as eosinophil infiltration in the lungs. However, nasal histology of the ovalbumin-sensitized mice showed no increase in eosinophil infiltration. The nasal lavage fluid revealed no increase in eosinophils or IL-5, and the nasal airway resistance did not increase after challenge either. CONCLUSIONS: In a mouse allergy model, exclusive allergen challenge of the lower airway can elicit a pulmonary and systemic allergic response, but does not induce upper airway inflammatory or physiological responses.

Effect of prone position ventilation on respiratory mechanics and prognosis in patients with acute respiratory distress syndrome concurrent with interstitial lung disease / 中华危重病急救医学

ObjectiveTo explore the effect of prone position ventilation (PPV) on respiratory mechanics and prognosis in patients with acute respiratory distress syndrome (ARDS) concurrent with interstitial lung disease (ILD). Methods The data of 36 severe ARDS patients admitted to Department of Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University from February 2013 to January 2015, were retrospectively analyzed. They were then divided into two groups according to the presence of ILD or not. The changes in respiratory mechanics and oxygenation indexes were compared before and after PPV treatment in all the patients. Kaplan-Meier method was applied to draw the 60-day survival curves of both groups.Results There were 17 cases with ILD among these 36 severe ARDS patients.① No significant difference was found in baseline data between ILD group and non-ILD group.② Respiratory mechanics and oxygenation pre-PPV and post-PPV: compared with pre-PPV, oxygenation index (PaO2/FiO2, mmHg, 1 mmHg = 0.133 kPa) post-PPV was significantly increased in both groups [ILD group : 132.0 (93.5, 172.0) vs. 118.7 (92.0, 147.8); non-ILD group: 126.1 (100.9, 170.0) vs. 109.2 (89.0, 135.0), bothP 0.05], and Crs was lower after PPV treatment in both groups, but without significant difference [non-ILD group: 22.7 (15.2, 27.1) vs. 24.3 (15.9, 48.9); ILD group: 16.2 (12.8, 25.6) vs. 18.9 (12.7, 27.3), bothP> 0.05].④ The 60-day mortality in ILD group was significantly higher than that in non-ILD group [88.2% (15/17) vs. 57.9% (11/19),P = 0.047). It was shown by Kaplan-Meier curves that 60-day survival patients in ILD group was significantly lower than those in non-ILD group (χ2 = 5.658,P = 0.017). Conclusions PPV can improve oxygenation in severe ARDS. Compared with non-ILD group, though the compliance of respiratory system in ILD group is increased during PPV, long-term effect is better in non-ILD group.