Involuntary cough strength and extubation outcomes for patients in an ICU.

BACKGROUND: Removing the artificial airway is the last step in the mechanical ventilation withdrawal process. In order to assess cough effectiveness, a critical component of this process, we evaluated the involuntary cough peak flow (CPFi) to predict the extubation outcome for patients weaned from mechanical ventilation in ICUs. METHODS: One hundred fifty patients were weaned from ventilators, passed a spontaneous breathing trial (SBT), and were judged by their physician to be ready for extubation in the Tri-Service General Hospital ICUs from February 2003 to July 2003. CPFi was induced by 2 mL of normal saline solution at the end of inspiration and measured using a hand-held respiratory mechanics monitor. All patients were then extubated. RESULTS: Of 150 enrolled patients for this study, 118 (78.7%) had successful extubation and 32 (21.3%) failed. In the univariate analysis, there were higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores (16.0 vs 18.5, P = .018), less negative maximum inspiratory pressure (-45.0 vs -39.0, P = .010), lower cough peak flows (CPFs) (74.0 vs 42.0 L/min, P < .001), longer postextubation hospital stays (15.0 vs 31.5 days, P < .001), and longer postextubation ICU stays (1.0 vs 9.5 days, P < .001) in the extubation failures compared with the extubation successes. In the multivariate analysis, we found that a higher APACHE II score and a lower CPF were related to increasing risk of extubation failure (odds ratio [OR] = 1.13; 95% CI, 1.03-1.25; and OR = 0.95; 95% CI, 0.93-0.98, respectively). The receiver operator characteristic curve cutoff point for CPF was 58.5 L/min, with a sensitivity of 78.8% and specificity of 78.1%. CONCLUSIONS: CPFi as an indication of cough reflex has the potential to predict successful extubation in patients who pass an SBT.

Pheochromocytoma presented as intestinal pseudo-obstruction and hyperamylasemia.

Pheochromocytoma has wide variations in alimentary presentations and complications. Here, we report a patient with pheochromocytoma who developed intestinal pseudo-obstruction and hyperamylasemia. The intestinal pseudo-obstruction responded promptly to intravenous infusions of phentolamine, an alpha-adrenergic blocker managed to control hypertensive crisis. The hyperamylasemia regressed gradually after resection of the tumor. The role of catecholamines liberated from the tumor is discussed in the associated pathogenesis. Early recognition of pheochromocytoma with gastrointestinal manifestations will facilitate proper management and prevent possible lethal outcome.

An outbreak of tuberculosis in a bacillus Calmette-guérin-vaccinated military population.

The purpose of this study was to investigate an outbreak of tuberculosis (TB) in a bacillus Calmette-Guérin-vaccinated military population and propose an appropriate method of control. We divided 593 subjects into "close contacts" and "non-close contacts" of an index case and examined all subjects by chest X-radiography (CXR). For "close contacts," we performed several tests for patients with abnormal CXRs. "Non-close contacts" had no pulmonary infiltration and no evidence of TB. We administered tuberculin skin tests (TST) to 21 "close contacts" who had pulmonary infiltrations. Seven patients had a TST > or =18 mm, two of whom had active pulmonary TB. We administered antituberculous agents to all seven patients for 6 months. Fourteen subjects with TSTs <18 mm had no evidence of TB during the 18-month follow-up period. Among the other 178 "close contact" subjects with no infiltrations evident on the initial CXR, one patient developed TB pleuritis. We conclude that it is important to use early treatment for "close contacts" of a TB index case by performing the TST and testing for pulmonary infiltration on CXRs.

Hepatic injuries of hexachloroethane smoke inhalation: the first analytical epidemiological study.

UNLABELLED: There has been no human epidemiological data regarding the hepatic injuries of hexachloroethane-zinc oxide (HC/ZnO) inhalation. This is the first epidemiological study to investigate whether HC/ZnO inhalation exposure can induce hepatic dysfunction in exposed soldiers. Twenty soldiers, exposed to high concentration of HC/ZnO smoke for 3-10 min in a narrow tunnel (0.6 m in width) during military training, were recruited as exposed group and they were divided into high-exposed group (n=10) and low-exposed group (n=10) by the distance from the explosion locale as a surrogate of exposure condition. Another 64 soldiers, not visiting the explosion areas, were recruited as referents. Venous blood was collected for liver function analyses. After log transformation of alanine aminotransferase (ALT) and adjustment for potential confounders, serum ALT in high-exposed soldiers was statistically significantly higher than those of referents for the 3 weeks following exposure. The serum ALT in low exposed soldiers was statistically significantly higher than those of referents at the 3rd week following exposure. The mean ALT levels also showed decreasing gradients by the distance from exposure locale. In addition, the proportions of abnormality on ALT (>40U/L) were also significantly different among three exposure conditions. Follow-up study showed that the hepatic dysfunction started from 1 to 2 weeks and peaked from 3rd to 5th week after exposure. ALT level was then returned to normal within 6-8 weeks after removing from HC/ZnO smoke exposure. No sequelas in hepatic dysfunction were found until 72 weeks follow-up. CONCLUSION: We concluded that inhalation of HC/Zn smoke can induce acute, dose-dependent and definite temporal relationship hepatic dysfunction.

Bell's palsy associated with influenza vaccination: two case reports.

The etiology of Bell's palsy is often unknown. We present herein two cases of adults who developed a Bell's palsy following the administration of an influenza vaccine. While the incidence is low, with the widespread recommendation for annual influenza vaccines, patients should be apprised of the possibility of this complication and the benefit of early treatment.

Cost benefits of targeting the pneumococcal vaccination program to the elderly population in Taiwan.

BACKGROUND: Because of the continuing rise in pneumococcal vaccine costs and limits on funding of such costs, vaccination priorities in Taiwan were assessed. METHODS: Data of a randomly selected sample of 200,448 people were analyzed to identify the highest risk groups. Patients were subgrouped on the basis of age and gender, and estimates were made of cumulative admissions, pneumonia recurrence rate, and associated costs of hospital care and medical treatment over the period 1997-2002 for each subgroup. RESULTS: The per capita costs of medical treatment for pneumonia in those aged 65 years or above were found to be highest in those with chronic lung disease (19,906,086 US dollars), heart disease (19,692,769 US dollars), and diabetes mellitus (8,613,973 US dollars). CONCLUSION: Elderly adults over age 65 years with these chronic diseases should be considered high-priority candidates for pneumococcal vaccination.

Acquired bartter-like syndrome associated with gentamicin administration.

Although acute nonoliguric renal failure is a well-known nephrotoxic effect of aminoglycoside antibiotics, less recognized is acquired Bartter-like syndrome. Herein, we describe four female patients who presented with marked paresthesia, muscle weakness, and tetany following gentamicin therapy with total dose ranging from 1.2 g to 2.6 g. All were normotensive. Biochemical abnormalities included hypokalemia (K+ 1.8-2.3 mmol/L), metabolic alkalosis (HCO(3-) 31.9-34.2 mmol/L), hypomagnesemia (Mg2+ 0.9-1.2 mg/dL), hypermagnesiuria (fractional excretion of Mg 3-6%), hypocalcemia (free Ca2+ 2.0-4.1 mg/dL), and hypercalciuria (molar ratio of Ca2+/creatinine 0.23-0.53), all consistent with Bartter-like syndrome. Serum immunoreactive parathyroid hormone concentration was low despite the hypocalcemia. The Bartter-like syndrome lasted for 2 to 6 weeks after cessation of gentamicin, coupled with supplementation of K+, Ca2+, and Mg2+. These biochemical abnormalities resembled those seen in patients with gain-of-function mutations in the calcium-sensing receptor. We hypothesize that gentamicin, a polyvalent cationic molecule, induces the action of calcium-sensing receptor on the thick ascending loop of Henle and distal convoluted tubule to cause renal wasting of Na+, K+, Cl-, Ca2+, and Mg2+.

A hidden cause of hypokalemic paralysis in a patient with prostate cancer.

Hypokalemic paralysis is a medical emergency due to the risks of cardiac arrhythmia, respiratory failure, and rhabdomyolysis. Besides supplementing patients with KCl to hasten recovery, the astute physician must search for the underlying cause to avoid missing a treatable and curable disorder. We report on an elderly Korean man who presented with marked limb paralysis, myalgias, and mild hypertension. He had prostate cancer treated with orchiectomy and hormone therapy 2 years previously. The major biochemical abnormalities were hypokalemia (K+: 1.7 mmol/l) associated with high renal K+ wasting and metabolic alkalosis (HCO3-: 42.6 mmol/l). Low plasma renin activity, low aldosterone concentration, and normal cortisol concentration pointed to a state of pseudohyperaldosteronism. While reviewing his drug history, the patient revealed he had been consuming eight packs (100 ml/pack) of a Korean herbal tonic daily to treat his prostate cancer for the past 2 months. A significant amount of glycyrrhizic acid (0.23 mg/ml), an active ingredient of licorice, was detected in the tonic. Discontinuation of the herbal tonic along with KCl supplementation achieved recovery in 2 weeks. As many complementary/alternative medicines for cancer contain licorice, this must be kept in mind as a cause of hypokalemia in cancer patients.

Hepatic effects in workers exposed to 2-methoxy ethanol.

The objective of this study was to investigate the effects of 2-ME on hepatic function in exposed workers. Fifty-three impregnation workers from two copper-clad laminate-manufacturing factories using 2-ME as a solvent were recruited as the exposed group. Another group of 121 lamination workers with indirect exposure to 2-ME was recruited as the comparison group. Environmental monitoring of air 2-ME concentrations and biological monitoring of urine 2-methoxy acetic acid concentrations were performed. Venous blood was collected for blood biochemistry analyses. Liver function examination results showed that the aspartate amino transferase, alanine amino transferase, and gamma-glutamyl transferase in the 2-ME-exposed workers were not significantly different from those in the comparison workers. After adjustment for hepatitis carrier status, gender, body mass index, and duration of employment, no difference were found between exposed and comparison groups. We conclude that 2-ME was not a hepatotoxin.

Influenza and pneumococcal vaccination of the elderly in Taiwan.

In 1998, Taiwan became the first country in Asia to provide free influenza vaccination to high-risk groups, mainly the elderly. The purpose of this study is to determine: (1) the annual mortality rate from influenza and pneumococcal-related illnesses such as pneumonia, chronic bronchitis, pulmonary emphysema and asthma and (2) the effectiveness of and adverse events associated with the influenza vaccination. In the elderly, influenza vaccination caused the annual death rate due chronic bronchitis, pulmonary emphysema, and asthma to decline steadily but had no effect on the annual pneumonia death rate. The only adverse effect of concern was vertigo (in approximately 2-3%).

Meta-analysis of standard mortality ratio in cotton textile workers.

BACKGROUND: Pulmonary function tests may reveal obstructive lung disease with altered forced expiratory volume in 1 s (FEV1) in cotton textile workers. Since 1930, many cohort studies have been performed to assess the disease mortality rate in cotton textile workers. MATERIALS AND METHODS: The authors performed a meta-analysis of the SMR results of these studies. RESULTS: From the meta-analysis, the SMRs were as follows: for all deaths, 0.792 in males and 0.873 in females; for cancers, 0.705 in males and 0.829 in females. DISCUSSION: The male cotton textile workers were healthier than the general population. The healthy-worker effect may be one of the causes, in general workers in industry have a better mortality patterns than those not working.

Treatment of digital hydrofluoric acid burns.

BACKGROUND: Hydrofluoric acid (HF) is one of the strongest inorganic acids and is used widely in industry. It differs from other acids in the mechanism of injury. The hydrogen ion readily penetrates the skin and causes destruction of deep tissue layers and even bone. METHODS: If HF burns to the digital skin, keep washing with large amounts of tap water for a minimum of 15 minutes. Then topically apply 2.5% calcium gluconate gel and massage for at least 40 minutes. Locally inject with 10% calcium gluconate solution if the pain persists. We studied the cases with HF finger burns in our hospital. RESULTS: In general, this procedure is effective in the treatment of fingertip hydrofluoric acid burns. In 2 cases, due to attentive treatment, posttreatment conditions were red swelling of the skin only. The posttreatment conditions of the 10 cases have good prognosis. In one case, the worker had very poor sense of first-aid awareness; after her burn was treated with running water, she didn't receive proper treatment immediately. The wound took 20 days to heal. In the last 2 cases, low concentrations of hydrofluoric acid entered the eyes, but after treated with running water, no aftereffects were suffered. CONCLUSIONS: An accurate occupational history and physical examination are important aspects in patient assessment. We hope that this report will assist practitioner to properly manage HF burns.

The association between frequencies of mitomycin C-induced sister chromatid exchange and cancer risk in arseniasis.

In order to examine whether biomarkers of cytogenetic damage and susceptibility, such as spontaneous and mitomycin C-induced sister chromatid exchange (SCE) can predict cancer development, a nested case-control study was performed in a blackfoot endemic area with known high cancer risk. A cohort of 686 residents was recruited from three villages in the arseniasis area. Personal characteristics were collected and venous blood was drawn for lymphocyte culture and stored in a refrigerator. The vital status and cancer development was followed using the National Death Registry, Cancer Registry, and Blackfoot Disease Registry. The follow up period was from August 1991 to July 1997. During this 6-year-period, 55 residents developed various types of cancer. Blood culture samples from 23 of these subjects were unsuitable for spontaneous SCE experiments and 45 of these subjects were unsuitable for mitomycin C-induced SCE experiments due to improper storage. Finally, a total of 32 cancer cases had cytogenetic samples that could be analyzed. About 32 control subjects were selected from those who did not develop cancer in the study period and these subjects were matched to cases by sex, age, smoking habits, and residential area. The results showed that there was no significant difference in the frequencies of spontaneous and mitomycin C-induced SCE between the case and control groups. There was also no significant difference in the net difference of spontaneous and mitomycin C-induced SCE between the case and control groups. These results suggest that SCEs, either spontaneous or mitomycin C-induced, might not be good markers to predict cancer risk.